Overlapping Universe Understanding Legal Insanity and Psychosis.docx

Overlapping Universe: Understanding Legal Insanity and
Psychosis
Zachary D. Torry • Stephen B. Billick
Published online: 6 April 2010 Springer Science+Business
Media, LLC 2010
Abstract The Insanity Defense of Not Guilty by Reason of
Insanity is the defense used by some mentally disordered
defendants who do not have the capacity for understanding right
and wrong at the time of their criminal act. This defense has
perplexed legal and mental health professionals for centuries.
Though it has been a part of the legal system since the early
Greeks, it has been and continues to be amended, modiﬁed, and
in some jurisdictions, abolished. Moreover, despite its
infrequent use, many in our society hold onto the belief that
defendants can evade criminal responsibility by means of this
defense. Furthermore, insanity is often equated with psychosis;
however, the two are not the same and have different
connotations. It is essential for any clinical psychiatrist to
understand the concept of the insanity defense and how it
differs from psychosis. This paper will clarify the meaning and
purpose of the insanity defense and will differentiate insanity
and psychosis.
Keywords Insanity defense NGRI Criminal action Mens rea
Introduction
The insanity defense has been a controversial and elusive
component of the legal and psychiatric professions for
centuries. It has long tantalized defendants and mystiﬁed jurors.
Furthermore, the concept that certain people may not be held
responsible for their actions by reason of their mental state
generates feelings of anger and disparity among some
individuals. The insanity defense is viewed by some as a
‘‘loophole’’ for defendants and a
Z. D. Torry Saint Vincent’s Hospital, Manhattan, NY 10024,
USA

Z. D. Torry (&) 140 West 79th Street, #4B, New York, NY
10024, USA e-mail: [email protected]
S. B. Billick New York Medical College, New York, NY, USA
123
Psychiatr Q (2010) 81:253–262 DOI 10.1007/s11126-010-9134-
2
scheme that clever attorneys and mental health professionals
exploit to acquit their criminal clients and permit dangerous
people to roam freely in society. Therefore, at times this
defense directs accusatory attention to the ﬁeld of clinical and
forensic psychiatry. The psychiatrist might be viewed as
creating excuses for the defendants’ otherwise criminal
behavior. Finally, it has been sometimes argued that the insanity
defense is inconsistent with the deterrent and punishment
purposes of criminal law. The reality is that the insanity defense
is used in only 1% of criminal cases, and it is used successfully
in only 10–25% of those [1]. Moreover, defendants who are
found insane generally spend as much or more time in state
custody than their criminally convicted counterparts [2].
Forensic psychiatrists are not the only psychiatrists who need to
understand the insanity defense. Patients seen in ongoing
clinical psychiatric treatment may commit crimes, and the
psychiatrist should have some appreciation for understanding
criminal responsibility. It is imperative for any treating clinical
psychiatrist to be versed in the applicable state and federal laws
on insanity because any treating clinical psychiatrist may be
called to testify on the mental status of their patient who has
been charged with committing a crime. Furthermore, a clinical
psychiatrist might be an unwitting victim in the hands of an
attorney who is trained in extracting certain kinds of
information from mental health professionals. This will result in
the clinical psychiatrist reporting deposition or trial testimony
that may be clinically accurate but not legally pertinent.
Moreover, a common misconception is to assume that if a
patient is psychotic, then that patient will qualify for insanity.
It is signiﬁcant to note the distinction between these two terms

as well as their implications. In a legal proceeding, a
psychiatrist may be requested to testify as either a ‘‘fact
witness’’ or an ‘‘expert witness’’ depending on the
circumstance. Therefore, it is helpful to understand the
difference between the two roles. A fact witness simply testifies
about direct observations. A common example would be a
treating psychiatrist who is asked to testify about his or her
patient’s symptoms and course of treatment. In this situation,
the psychiatrist is not ordinarily asked to give opinions. An
expert witness has ‘‘special knowledge’’ that the average
person may not possess, and it is the role of an expert witness to
educate the court on matters beyond which a layperson might
know. The psychiatric expert witness may testify in the form of
an opinion about facts directly related to the profession of
psychiatry [3]. This role is commonly attributed to a forensic
psychiatrist. This paper will serve as a literature review and
discussion in the hopes of clearing some of the cloudiness
behind the definition, practice, and purpose of the insanity
defense. It will also clarify the distinction between insanity and
psychosis.
Definition and Purpose
One reason for the controversies surrounding the insanity
defense is the different language used in the fields of criminal
law and mental health. Each field has varying ways of
expressing similar ideas but using different sets of terminology.
The temptation is to group these different sets of terms under
one definition. However, as will be seen in this paper, there are
very different meanings. In order to have a better grasp of the
insanity defense, one-first must understand the legal definitions
of criminal conduct and insanity. Then, perhaps the purpose of
the insanity defense can be better clarified.
254 Psychiatr Q (2010) 81:253–262
123
A criminal act must have two components: evil intent (mens rea,
literally ‘‘guilt mind’’) and action (actus reus, literally ‘‘guilty
act’’). The intent requires purposely or knowingly committing

the act that is proposed to cause harm. In addition, there cannot
be legal evil intent when an offender’s mental state is so
diseased, deficient, or abnormal as to have deprived the offender
of rational intent. The act itself must be voluntary and
conscious. Neither the act, however heinous, nor the intent to do
harm, is by itself, a criminal action. Both elements must be
proved beyond a reasonable doubt. For example, a prudent
reasonable driver might hit an icy patch on the road, causing the
car to kill an innocent bystander. This might not be a criminal
action as there was no criminal intent. Likewise, a spouse who
catches his or her partner in an extramarital affair might become
so enraged as to have intent to harm the spouse in retribution.
However, merely the intent to harm without actually doing it
might not be a criminal action. Insanity is a legal term rather
than a psychiatric or scientific one. Black’s Law Dictionary [4]
defines it as ‘‘any mental disorder severe enough that it
prevents a person from having legal capacity and excuses the
person from criminal or civil responsibility. Insanity is a legal,
not a medical, standard.’’ It is a disorder that impairs the human
mind and prevents distinguishing between actions that are right
or wrong. Mental illnesses are disorders of the brain that disrupt
a person’s thinking, feeling, moods, and ability to relate to
others. They are brain disorders resulting in a diminished
capacity for coping with the demands of life (National Alliance
for the Mentally Ill)[ 5]. The purpose of the insanity defense is
based on two medicolegal forces [6]. The first is the moral
imperative; this is the reluctance to hold responsible those who,
because of their developmental, psychological, or neurological
condition, lack the capability necessary to understand their own
actions. In Durham v. United States [7], Judge David Bazelon
wrote, ‘‘Our collective conscience does not allow punishment
where it cannot impose blame.’’ It is therefore inappropriate to
punish unless the person has the capacity to ‘‘make autonomous
choices over their behavior’’ [8]. Just as it is morally
inappropriate to condemn a child for behavior she or he is not
old enough to understand, persons who are ‘‘insane’’ cannot

have the intent necessary to perform a criminal act. These
persons either do not know that the act is wrong or cannot
control their actions even when they understand that the act is
wrong. This is the corresponding item to one aspect of the
definition of legal evil intent stating that the individual must
have rational intent in order for there to be legal evil intent. The
second component of the purpose of the insanity defense is the
concept of fairness––that is, to not hold those with a ‘‘mental
disease or defect’’ (defect is a legal reference to mental
retardation or a structural brain problem) to the same standards
of a responsible and functional person without a mental illness.
Developmental Competency (To do Wrong)
The age at which our society accords the autonomy in making
decisions and in accepting the responsibility for those decisions
is also a relevant topic. During earlier times, adult status was
usually accorded with the achievement of pubertal maturation
[9]. This is at age 13 years for Jewish teenagers at their Bar/Bat
Mitzvah. It is also at age 13 years for Christians when they
receive confirmation to ‘‘confirm as an ‘adult’’’ their desire to
join the church, which their godparents had made for them when
younger. Puberty was the biologic marker that coincided with
the transition from childhood to adulthood [9]. Piaget [10] also
found that age 12–13 years was the time of cognitive
achievement of concrete operational
Psychiatr Q (2010) 81:253–262 255
123
thinking (concrete logic). Since most people do not actually
achieve formal operational thinking (abstract logic), age 12–13
years would be the standard expected for an adult. This can also
be seen in current research on the developmental changes of the
human brain during this transition period. Using fMRI studies
in teens, the amygdala, an area involved in instinctual and
emotional reactions, was activated in identifying emotional
expressions and decision-making. As the subjects got older, the
activation area shifted to the frontal lobe [11]. The frontal lobe
regulates behavior and is involved in decisions regarding right

and wrong as well as cause and effect. Executive functioning in
the frontal lobe helps to distinguish humans from other animals.
Therefore, the age at which our society grants decision-making
capacity and moral reasoning has roots in biology as well as
religion. Society has changed the age of responsibility over
time. In the 19th century, it was closer to age 12–14 years, and
after 1899, with the first juvenile justice court established, it
became 18–21 years of age. In the late 20th century, there was
some return to younger ages being held responsible. It is now
the state which establishes capacity for mens rea and thus
responsibility for criminal actions.
History and Development of the Insanity Defense
A brief review of the history of the insanity defense might
facilitate a better understanding of it. The insanity defense has
been well established in the law for centuries. Nonetheless, it
has been ratified, amended, and altered many times over and
still sometimes brings consternation to the public. The insanity
defense has been recognized since the time of Aristotle [12], but
it was initially only a way for a defendant to receive a pardon or
a way to mitigate a sentence. The first recorded case of outright
acquittal by reason of insanity occurred in 1505 [13]. The
written law dates back to 1581 when a legal treatise
distinguished between those who understood the difference
between good and evil and those who did not. William
Lambarde stated the first insanity test, ‘‘If a madman or a
natural fool (congenitally retarded), or a lunatic in the time of
his lunacy (episode of disorder), or a child that apparently hath
no knowledge of good nor evil do kill a man, this is no
felonious act… for they cannot be said to have any
understanding will.’’ In the 1724 English case of Rex v. Arnold
[14], Arnold, a known madman killed a nobleman, Lord Onslow,
in the delusion that the victim had ‘‘bewitched him.’’ Using this
case, the British courts further developed the idea of the
insanity defense. Judge Tracy wrote that if a defendant was
‘‘totally deprived of his understanding and memory and doth
not know what he is doing, no more than an infant, than a brute,

or a wild beast,’’ he would not be held responsible for his
crime. This idea became known as the ‘‘wild beast’’ test, and it
based the standard on the level of understanding of the act of
the defendant.
The M’Naghten Test
Further evaluation of this standard and modification came in
1843 during the case of Daniel M’Naghten [15]. Mr. M’Naghten
was a Scottish woodcutter who assassinated Edward Drummond,
the secretary to the Prime Minister, Sir Robert Peel. He
believed that he was being persecuted by the Prime Minister’s
political party and was being spied on. He said, ‘‘(they) have
compelled me to do this. They follow, persecute me wherever I
go,…’’. He believed that the Prime Minister was responsible for
a myriad of personal and financial misfortunes that had befallen
him. During his trials, various witnesses testified to his ‘‘odd
256 Psychiatr Q (2010) 81:253–262
123
behavior’’ and complaints of persecution in the years prior to
the murder. The defense also called medical experts to testify
that M’Naghten’s delusions had deprived him of ‘‘all restraint
over his actions’’. The jury acquitted him and found him ‘‘not
guilty by reason of insanity.’’ The verdict concerned many, and
among them was Queen Victoria, who requested that the House
of Lords review this with a panel of judges. The House of Lords
put five questions before the Court of Common Pleas and asked
the judges to give an advisory opinion on the law governing
these cases. What emerged became the basis of the standard law
governing criminal responsibility in cases of insanity. This
stated that ‘‘to establish a defense on the grounds of insanity, it
must be clearly proved that, at the time of committing the act,
the accused was operating under such a defect of reason, from a
disease of the mind, as to not know the nature and quality of the
act he was doing, or if he did know it, that he did not know
what he was doing was wrong.’’ Furthermore, it must be proved
that the accused, at the time of committing the act, did not know
the difference between right and wrong. Therefore, this forces

the jury to get inside of the mind of the accused and to
determine whether the accused is able to understand not only if
the accused comprehends his action to be against the law but
also if the accused was able to govern his behavior according to
the law. Chief Justice Tindal noted in the case of M’Naghten,
that if the defendant is acting under the influence of an insane
delusion, he is punishable if he knew at the time of committing
the crime that he was acting contrary to law. However, if he
believed that he was acting in self-defense based on his
delusion, he would be excused. This also rejected the moral
standard, that is, the accused believed that he was morally
justified in his behavior, even though he might have known that
his acts were against the law. For example, if a person murders
an abortion doctor because he views the doctor’s behavior as
morally wrong, the law would not excuse the murderer just
because he believed that he was morally justified. This was
adopted by most jurisdictions in the United States and Great
Britain and became the standard test for insanity. It continues to
be the standard for insanity in half of the states today.
‘‘Irresistible Impulse’’
In the late 1880s, there came an alternative to the cognitive only
M’Naghten rule in the form of adding a volitional component,
the ‘‘Irresistible Impulse’’ Test. This still required that the
M’Naghten questions be asked, but it also suggested that an
‘‘insane’’ or ‘‘irresistible’’ impulse could remove reason, and
therefore, the ability to know or to choose between right and
wrong. This is also referred to as the ‘‘policeman-at-the-elbow
law’’ which means that an impulse is irresistible only when it
can be determined that the accused would have committed the
act even if a policeman had been at the accused’s elbow. This
did not gain wide acceptance, as mental health professionals are
unable to determine whether a crime was committed because the
defendant did not or could not exercise self-control.
Durham and the Product Test
During the 1950s, there was a growing dissatisfaction with the
M’Naghten rule’s being too rigid, perhaps as a result of the

growth of medicine and psychiatry. In particular, the ‘‘mind’’
and ‘‘body’’ connection, with the development of the biological
aspects of psychiatry, was a popular notion. It was felt that
there was not enough medical evidence brought into the insanity
defense. Therefore, in 1954, when the United States Court of
Psychiatr Q (2010) 81:253–262 257
123
Appeals for the District of Columbia heard the case of Durham
v. United States [7], the appellate judge seized this opportunity
to discard the M’Naghten rule and the ‘‘irresistible impulse’’
test and apply a broad and more medically based standard to
develop a new rule. He stated that ‘‘an accued is not criminally
responsible if his unlawful act was the product of mental
disease or defect.’’ This was not met with much popularity for
the primary reason that it cast a very broad net that could
include substance abusers and compulsive gamblers, among
others. This was based on the interpretation that mental disease
actually causes behavior, and this alone is too controversial to
be applied to the defense.
A.L.I. and the Model Penal Code
In 1962, the American Law Institute, a non-governmental
organization of lawyers, judges, and academics, set out a
proposed statute for use as a model for legislation around the
country in an effort to standardize penal law. A key feature is
its use of standardized mens rea terms to determine levels of
mental states. The model insanity defense statute softened the
M’Naghten standard and was based on the District of
Columbia’s decision in the federal appellate case, United States
v. Brawner, and adopted in 1972. The formulation [Sect. 4.0, 1]
of the Model Code states the insanity defense as ‘‘A person is
not responsible for criminal conduct if at the time of such
conduct as a result of mental disease or mental defect, he lacks
substantial capacity either to appreciate the criminality
[wrongfulness] of his conduct or to conform his conduct to the
requirements of the law.’’ The formulation contains elements of
all three prior standards––the concept of right and wrong from

the M’Naghten standard; the condition of lack of control from
the ‘‘Irresistible Impulse’’; and the diagnosis of mental disease
of defect from the Durham Rule. There also is a cognitive
aspect that addresses the defendant’s capacity to ‘‘appreciate
the criminality of his conduct.’’ Additionally, there is a
volitional aspect that addresses the defendant’s capacity to
‘‘conform’’ to the ‘‘requirements of the law.’’ The Model Penal
Code allowed for the introduction of medical and psychiatric
evidence by requiring that the mental disease or defect be a
medical diagnosis. All of the previous formulations of the
insanity defense require that the defendant be suffering from
‘‘mental disease or defect’’; however, this was not defined until
1962 in the District of Columbia during McDonald v. United
States [16]. The definition that emerged was ‘‘any abnormal
condition of the mind which substantially affects mental or
emotional processes and substantially impairs behavior
controls.’’ This was reaffirmed in United States v. Brawner, so
the A.L.I. standard also excludes defendants whose mental
illness or defect only manifests itself in criminal or antisocial
conduct. The model penal code gained wide popularity and as of
1982, the states were roughly split between the two standards:
22 states used some form of the A.L.I. rule, and 26 states used a
version of the M’Naghten rule.
The Hinckley Trial and its Aftermath
In 1981, John Hinckley Jr. shot then-United States President
Ronald Reagan, a secret service agent, a Washington police
officer, and Reagan’s press secretary in an attempt to gain the
attention of and impress Jodie Foster, a well known actress. Mr.
Hinckley was obsessed with Ms. Foster and, in a letter to the
New York Times, described the shootings as ‘‘the greatest love
offering in the history of the world…’’ In 1982, a District of
Columbia jury acquitted Mr. Hinckley and found him Not Guilty
by Reason of Insanity. This caused
258 Psychiatr Q (2010) 81:253–262
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an immediate public outcry. The outrage against the insanity

plea provoked immediate calls for the abolishment, or at least a
revision, of the insanity plea. In this trial, more than any other
up to that time, the psychiatrists and the law that allowed their
testimony were made the culprits for this verdict. The American
Bar Association and the American Psychiatric Association
issued statements calling for a change in the law. Congress
responded to this by introducing legislation designed to abolish
or modify the insanity defense. The results were that the federal
courts shifted from the A.L.I standard to a stricter version for
the insanity defense in federal crimes. This became The Insanity
Defense Reform Act of 1984 and was the first federal legislation
governing the insanity defense and the disposition of
individuals suffering from a mental illness involved in the
criminal justice system. This version stated that the ‘‘defendant,
as a result of a severe mental disease or defect, was unable to
appreciate the nature and quality of the wrongfulness of his
acts.’’ This eliminated the Irresistible Impulse test (the
volitional element) and more closely resembled the M’Naghten
rule. It also stated that the defendant must show that his mental
disease or defect is ‘‘severe.’’
Burden of Proof
Furthermore, Congress enacted some provisions that toughened
the barriers to the insanity defense. One of these is the Burden
of Proof, specifically, on whom the burden of proof should be
placed. This is the legal obligation of one side––prosecution or
defense––to convince the judge or jury (decision maker) to
some specified degree of certainty that their depiction is true. In
this defense, it will determine which side will lose if the jury
finds itself unable to determine (with whatever degree of
certainty the law may specify) whether the defendant was or
was not legally insane [8]. Before Hinckley, the burden of proof
in federal cases was on the prosecution to prove beyond a
reasonable doubt that a defendant was sane. In the aftermath of
the Hinckley trial, the position has shifted. Of the states that
continue to allow the insanity defense, two-thirds of which
assert that the defendant bears the burden of convincing the jury

that she or he was insane by a preponderance of evidence
(lowest level of proof). Similarly, under federal law, the
defendant bears the burden but by a more demanding standard,
clear and convincing evidence (stricter requirement). The state
bears the burden of proof on mens rea.
State Responses
In the wake of the Hinckley case, many states made changes to
their insanity defense statutes. Four states (Kansas, Idaho,
Montana, and Utah) dropped the insanity defense altogether;
although two of those four (Montana and Utah) have the
alternate ‘‘Guilty but Mentally Ill’’ (see below). Most others
adopted various standards, such as a stricter version of the
insanity defense or shifted the burden of proof, in ways to make
it more difficult to sustain an insanity plea. In addition, some
states enacted laws providing for more restrictive confinement
options for those acquitted by reason of insanity.
Guilty but Mentally Ill
In addition to abolishing the insanity defense and adopting
stricter standards to apply or prove the defense, about one-
fourth of the states have established a separate verdict of
‘‘Guilty but Mentally Ill’’ (GBMI). This is used as an
alternative (not instead of) the
Psychiatr Q (2010) 81:253–262 259
123
insanity defense. The consequence of receiving GBMI is that
the individual is convicted and given a criminal sentence. It is a
verdict available to the jury when the conclusion is that the
defendant committed the act charged but suffers from a mental
disorder, however, not at the level necessary to meet the
insanity defense.
Psychosis
Psychosis is a scientific term. The Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR) [17] defines it as
‘‘Delusions and prominent hallucinations, with the
hallucinations occurring in the absence of insight into their
pathologic nature.’’ In the Comprehensive Textbook of

Psychiatry [18], Benjamin Saddock, M.D. defines psychosis as a
‘‘mental disorder in which the thoughts, affective response,
ability to recognize reality, and ability to communicate and
relate to others are sufficiently impaired to interfere grossly
with the capacity to deal with reality; the classical
characteristics of psychosis are impaired reality testing,
hallucinations, delusions, and illusions.’’ The cause is a variety
of psychiatric and medical problems. There is no mention in this
definition of psychosis of preventing a person from
distinguishing between actions that are right or wrong.
Therefore, for the clinical psychiatrist, it should be made clear
that psychosis does not equal insanity. It is very possible for a
defendant to be psychotic but not considered insane. It is
equally possible, though less likely, for a defendant to be found
insane but not meet the qualifications for psychosis. In most
cases of Not Guilty by Reason of Insanity, the defendant is in
an active state of psychosis at the time of the crime. This is to
say that crimes committed by those found to be psychotic are
not excused on the basis of the psychotic diagnosis. In fact, the
diagnosis is not as important as ‘‘how it affected (a person’s)
ability to do certain things at the time of the allegedly criminal
act’’ [19]. Furthermore, agreement on whether or not a
defendant has psychosis rarely approaches a level as high as
90% even when the clinicians come from the same background
[20]. It is imperative to understand the difference between
psychosis and insanity and to be able to apply this difference.
Consider the case of a defendant who is having persecutory
delusions and paranoid ideation and kills his psychiatrist for
having him hospitalized. The defendant might have known at
the time of the act that it was wrong but still committed the act.
In 1998, Andrew Goldstein was a defendant with a known
psychiatric history and who claimed to be having auditory
hallucinations at the time of the crime. Nonetheless, a jury
found him guilty of second-degree murder for pushing Kendra
Webdale in front of an oncoming Manhattan subway train.
Similarly, in the controversial 2006 Supreme Court Case of

Clark v. Arizona [21], the defendant suffered from
Schizophrenia, Paranoid Type and was actively psychotic at the
time of the crime. Nevertheless, he was convicted of firstdegree
murder of a police officer. Additionally, there are cases such as
the Dan White murder trial of San Francisco Mayor George
Moscone and Supervisor Harvey Milk. In this case, the
defendant was convicted of manslaughter rather than murder on
the basis of his symptoms of severe depression (not psychosis).
Conclusion
Although one of the most controversial and elusive components
of the legal and psychiatric professions, the Insanity Defense,
nevertheless, has great significance. Summarized briefly,
260 Psychiatr Q (2010) 81:253–262
123
a criminal act consists of the illegal act itself and the intention
to commit the illegal act. The insanity defense is some variation
of: A defendant must be found not guilty by reason of insanity
if, at the time of the alleged offense, and as a result of severe
mental disease or defect, he did not know what he was doing or
that what he was doing was wrong. As simple as this might
sound, a cursory look into it’s history reveals a glimpse of the
inherent complexities. Nevertheless, despite the confusion and
the infrequent use, its application must be clearly understood by
any treating mental health professional. Moreover, the
temptation to understand insanity as psychosis is present but
completely unfounded. The two terms are not only different but
also are the products of the use of different languages in the
fields of law and psychiatry. This contributes to the confusion
and can result in the misrepresentation of information in
criminal proceedings, which clearly, will have significant
consequences. The clinical psychiatrist who finds himself or
herself with a patient charged with a crime needs to be quite
careful to understand how the patient’s mental illness may have
or may have not contributed to the commission of the crime. It
might be prudent to get a consultation from a forensic
psychiatrist to help the clinician clarify the important issues and

determinants.
References
1. Callahan LA, Steadman HJ, McGreevy MA, Robbins PC: The
volume and characteristics of insanity defense pleas: an eight-
state study. Bulletin of the American Academy of Psychiatry
and Law 19(4):331–338, 1991 2. Rodriguez J, Lewinn L, Perlin
M: The insanity defense under siege: legislative assaults and
legal rejonders. Rutgers Law Journal 14:397–430, 1983 3.
Resnick PJ, Knoll J IV: Being an effective psychiatric expert
witness. Psychiatric Times 24(6), 2007 4. Garner BA: Black’s
Law Dictionary, 8th edn. Thomson West, 2004 5. National
Alliance of the Mentally Illness (NAMI) 6. Saddock BJ,
Saddock VA: Kaplan and Saddock’s Synopsis of Psychiatry, 9th
edn. Philadelphia, 2003 7. Durham v United States: 214 F.2d
862, D.C. Cir. 1954 8. Bonnie R, Jeffreis JC Jr, Low P: A Case
in the Insanity Defense: The Trial of John W. Hinckley Jr, 3rd
edn. New York, Thomson/Foundation Press, 2008 9. Billick SB:
Developmental competency. Bulletin of the American Academy
of Psychiatry and Law 14(4):301–309, 1986 10. Inhelder B,
Piaget J: The Growth of Logical Thinking. New York, Basic,
1958 11. Baird AA, Gruber SA, Fein DA, et al.: Functional
magnetic resonance imaging of facial affect recognition in
children and adolescents. Journal of the American Academy of
Child and Adolescent Psychiatry 38(2):195–199, 1999 12. Irwin
T (translator): Nichomachean Ethics, Book III, 2nd edn.
Indianapolis, Hackett Publishing Company, Inc., 1999 13.
Robitscher J, Haynes AK: In defense of the insanity defense.
Emory Law Journal 31:9–60, 1982 14. Rex v. Arnold: 16 How.
St. Tr. 695, 1724 15. M’Naghten’s Case: 8 Eng. Rep. 718, 1843
16. McDonald v. United States: 312 F.2d 847, 851 1962 17.
American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, 4th edn., Text revision.
Washington, DC, 2000 18. Saddock, BJ: Signs and Symptoms in
Psychiatry. In: Saddock BJ, Saddock VA, Ruiz P (Eds) Kaplan
and Saddock’s Comprehensive Textbook of Psychiatry, 9th edn.,
Vol. 1. Philadelphia, Williams & Wilkins, 2009 19. Reid WH:

The insanity defense: bad or mad or both? Journal of
Psychiatric Practice 69–172, 2000 20. Field SJ: Book review:
conducting insanity evaluations. American Journal of Criminal
Justice 111–114, 1986 21. Clark v. Arizona: 548 U.S. 735, 2006
Psychiatr Q (2010) 81:253–262 261
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Author Biographies
Zachary D. Torry M.D. is currently a Chief Resident in the
Department of Psychiatry at Saint Vincent’s Hospital,
Manhattan, New York. He will be a fellow in Forensic
Psychiatry at The University of Pennsylvania School of
Medicine in 2010–2011.
Stephen B. Billick M.D. is Clinical Professor of Psychiatry at
New York Medical College and Associate Chair for Faculty
Development in the Department of Psychiatry at Saint Vincent’s
Catholic Medical Center/ New York Medical College. He is
President of The American Academy of Psychiatry and the Law
as well as a practicing Forensic and Child and Adolescent
Psychiatrist in New York City.
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Overlapping Universe Understanding Legal Insanity and Psychosis.docx