“Long haul cognitive effects of Covid-19” in those who have “recovered”

There are now sufficient numbers of individuals who have had the coronavirus during the past 15 months who are presenting to their physicians with lingering symptoms of the disease. They are now known as long-haulers. People who have sometimes multiple complaints that suggest to researchers that they are a different group of patients. They tend to be younger, they generally have more complex medical histories including a variety to pulmonary conditions, and they are not the case you might expect to be most debilitated. This report is derived from the literature recent review and live zoom presentation on the Cognitive Impact on Long-haul survivors of the coronavirus held on May 20, 2021. It is available on the Whittier Health website. I want to thank Lauren Guenon, MS, SLP, CBIS for her help in this program and the data mining we are continuing.

Coronavirus molecule under magnification

It was first reported that overwhelming viral spread was thought to be primarily respiratory. The virus multiplies inside the body and is likely to cause mild symptoms that may be confused with a common cold or flu. This changes in many as the viral load evokes a cytokine autoimmune response in the body. As the virus takes, hold during the worsening pulmonary phase primarily respiratory symptoms such as persistent cough, shortness of breath, and low oxygen levels are observed. Too many survivors say the ignored this phase and just tried to rest at home. Often they were transported to hospital after being overwhelmed by the inflammation in their lungs and other organs. Hyperinflammatory phase, occurs when a hyperactivated immune system may cause injury to the heart, kidneys, and other organs as covid-19 devours healthy cells leading to death of cells in a process called apotosis.

Experience shows most long-haulers were expected to fall into the high risk category. like those with chronic COPD, but there is also a growing percentage of people who were otherwise healthy before they became infected and are not the older, sicker cases first described.

About 33% of COVID-19 patients who were never sick enough to require hospitalization continue to complain months later of symptoms like fatigue, loss of smell or taste and “brain fog,” that can interfere with functional tasks including the return to work.

University of Washington (UW)

It remains unclear if neurological complications are due to the direct viral infection of the nervous system, or they are a consequence of the immune reaction against the virus in patients who presented pre-existing deficits or had a certain detrimental immune response from their immunocompromised status when infected. 38 males, ages 22-74

The first studies of long haul survivors are being published. They are small studies reporting on the Italian first wave in 2020. The cases are hospitalized, non-intensive COVID units in Milan, Italy. These were not the patients who needed intubation or ventilatory support. Most had ARDS (mild, moderate, severe) Ferrucci, R et al. Subjectively, 31.6% reported overall cognitive decline 4-5 months after discharge when they were screened using a commonly administered cognitive test, then assessed using BRB-NT. Results for this group of moderately infected patients included: 42.1% processing speed deficits; 26.3% delayed verbal recall; 10.5% immediate verbal recall; 18.4% impaired visual long term memory, 15.8% visual short term memory; and 7.9% semantic verbal fluency deficits. Helms et al. reported on 58 patients who were evaluated in the ICU with over a third (33%) exhibiting dysexecutive syndrome, poorly deployed attention, and decreased capacity for organization

In another Italian study, 81% of patients had cognitive deficits including difficulty in areas of attention and executive functioning with pronounced weaknesses in divided and sustained attention (complex attention) set-shifting, speed of processing, and working memory. This was a group of 57 patients who were sent to acute rehabilitation after they were cleared of having active virus. All were debilitated and had a mean age of 64. 75 percent were male, 61 percent non-white and 56 percent were fully employed. In this group 88 % had suffered hypoxic respiratory failure with most being intubated for ventilatory support. 29% went on to get a tracheostomy tube inserted indicating a likely longer-term need for breathing support. 84 % need assistance with activities of daily living, has impaired mobility, and support for IADL’s. Neuropsychology services saw them an average 6.6 days after admission to the rehabilitation hospital. In general, the Whittier cases admitted for covid-recovery were referred to a neuropsychologist within 48 hours of admission. Ventilation-induced hypercapnia has been experimentally shown to lead to cognitive impairment due to acute inflammatory response advancing the cytokine storm and its multi-system impact.

Studies have described long-term risk and short-term risk to cognitive health from the coronavirus. Severe cognitive decline like dementia may be associated with co-occurring illness from anoxia, respiratory failure, blood clots and is associated with more severe disease and chronic long lasting symptoms. These are linked to prolonged risk of systemic inflammatory illness, increased risk of stroke and white matter disease within the brain and even reported cases of acute transverse myelitis (Budson,A, 2021). Budson reported on symptoms in 30-50 percent of people who experienced mild to moderate disease. Zhou et al. described a sample of 29 patients who were assessed 3 weeks after discharge home who were found to have dysfunction in the system of attention – most notably in sustained attention and reaction time. This may be the result of decreased mental endurance, slow processing and fatigue that are reported across several studies reported here. These patients were positively coorlated with C-reactive protein – a marker of the bodies inflammatory response when elevated.

Elevated level of CRP may be a valuable early marker in predicting the possibility of disease progression in non‐severe patients with COVID‐19, which can help health workers to identify those patients an early stage for early treatment.

Nurshad, A 2020

Rampage published in the table below in the American Journal of Speech Pathology in 2020. The long-haul covid-recovered are likened to patients described as having post-intensive care syndrome that occurs as a result of the changes in the system of cognition and emotional regulation. This is one of the best tables I have seen that illustrates the impact of the virus and the systems that are impacted. Rampage et al.

Delirium is another concern and fits in with what is called post-ICU syndrome (PICS), a collection of problems that can present—and linger—after a critical illness.  “The three domains we worry about are impairments in physical function, cognitive function, and mental health” .

Yale School of Medicine Carrie MacMillen June 2020 

The long term impact may be seen later on in life. Chronic systemic inflammation has been shown to promote cognitive decline and neurodegenerative disease makes it more likely that COVID-19 survivors will experience neurodegeneration in later years that has been known for a long time. Those with short term cognitive consequences may have had less viral load and for a shorter duration of time. Interestingly, those who were in covid-recovery units and on ventilators tended to report less cognitive symptoms suggesting there may have been some protective element to consistent ventilatory or simply timing and getting to the hospital before the hyperinflammatory (cytokine storm) phase of the viral process.

Whittier Rehabilitation Hospital in Westborough, MA is looking at the data of 73 patients. This is very likely the first and largest subset of surviving long haul cases of the coronavirus. Our population is older 70.6 years, 66% white males versus approximately 64 years reported in the Italian studies reported here. The Italian samples were largely male as well. The average length of stay was 19.6 days. 21% had signs and symptoms of clinical depression or generalized anxiety co-occurring with their physical and cognitive symptoms. 14% had persistent delirium and encephalopathy.

Recovery from the long-haul symptoms reported in this paper will take weeks to months we predict. It has been recommended that aggressive multidisciplinary rehabilitation be initiated as soon as endurance permits. Intensity shoould include 4-5 times a week PT, OT, and speech language pathology. In many cases the comorbid depression and anxiety must be dealt with concurrent to the restorative physical and cognitive work. Some have likened the neurocognitive impact of covid-19 to that of a moderate traumatic brain injury in the breadth of its impact and tough return to a semblance of normalcy. Aggressive treatment is strongly recommended and should be commensurate with endurance and debility. There is evidence that the likelihood of full return to work is decreased after 6 months or more of recovery.


References

Ferrucci, R et al., (2021) Brain Sci. 11, 235.

Jaywant et al., (2021) Neuropsychopharmacology, 0:1-6

Budson, A. (2021) B.U.Medical School — https://www.health.harvard.edu/blog/author/abudson

Heneka et al. (2020) Alzheimer’s Research & Therapy. Long and Short-term Cognitive Impact of Coronavirus. 12:69 https://doi.org/10.1186/s13195-020-00640-3

Lawton, MP, Brody, EM. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 9(3): 179-186.

Ramage, A. Potential for Cognitive Communication Impairment in COVID-19 Survivors:  A Call to Action for Speech Language Pathologists.  Nov. 2020, American Journal of Speech-Language Pathology.  Vol. 29. 1821-1832 

Sigurvinsdottir, R, Thorisdottir, I, Gylfason, HF. (2020). The Impact of Covid-19 on Mental Health: The role of Locus of Control and Internet Use. International Journal of Environmental Research and Public Health, 17:6985: doi:10.3390/ijerph17196985.

Nurshad, Ali, (2020) J Med Virol. Jun 9 : 10.1002/jmv.26097.


Law Enforcement and Mental Health: Insanity rules the day

Westborough, MA August 30, 2018 In the process of writing the Police Chief’s Guide to Mental Illness: Mental Health Emergencies, Leo Polizoti, Ph.D. my co-author and I quickly discovered that it is often not easy to identify people experiencing mental health crisis or emergency.  Many are not forthcoming with the specific underpinning of their particular disorder because of embarrassment and shame associated with mental disability. For many the stigma of being labelled “mentally ill” is more than they can bear. Nevertheless, “the Treatment Advocacy Center, a nonprofit that studies topics related to mental health, has calculated that the odds of being killed during a police encounter are 16 times as high for individuals with untreated serious mental illness as they are for people in the broader population” according to Nathaniel Morris, M.D. in an article espousing the benefits of having psychiatric physicians under contract to provide consultation for police encounters with the mentally ill.
A program in Albuquerque, NM does just this by having a full-time physician on the staff for both training and face-to-face consultation. This is a costly endeavor whereas the average psychiatrist earns nearly $ 200,000 annually. The thought is that as a medical doctor greater acumen in distinguishing organic syndromes like dementia from more common disorders such has depression or anxiety. I agree but other clinicians when properly trained may provide similar expertise at a more cost effective salary. Many co-responder programs have master’s level clinicians riding with law enforcement. Generally a physician is employed when you expect patients or such clientele to be prescribed medication and follow up.  My sense of the New Mexico program does not include medication management in its charge. Yet even physicians have difficulty differentiating the sane from the psychologically unwell.
In a famous study, Rosenhan suggests that the label associated with being schizophrenic causes the hospital staff to make misguided assumptions about the patients’ behavior through no fault of their own.  When someone is seen as mentally ill, everything they do may be interpreted as symptomatic of their disorder.
The psychological autopsy method entails reconstructing a biography of the deceased through psychological information gathered from personal documents; police, medical, and coroner records; and first-person accounts, either through depositions or interviews with family, friends, coworkers, school associates, and physicians. One of the major contributions of psychological autopsies “has been to introduce the psychosocial context into decisions about the cause of death since examination of postmortem remains tell only what lesions the patient died with, not what he died from.”
”Studies have shown that there are certain commonalities to suicide completers. Indeed, “they found that persons who commit suicide are likely to be unmarried, unemployed, living alone, and depressed”. Clark et al. found that suicide completers are twice as likely to be male, almost always qualify for a psychiatric diagnosis, and more often than not communicate intent. Sanborn et al found that the protoypical suicidal individual is not currently employed, is experiencing acute stress and frustration in areas apart from work, and has an alcohol problem. Moreover, such risk factors for suicide have been found to vary by age group. Adolescent suicide completers often have a history of physical and sexual abuse, parental psychiatric problems, and commit suicide in the context of an acute disciplinary crisis, elderly suicide completers often have a history of chronic or terminal disease. Persons who are addicted to alcohol or drugs and are having suicidal ideation are more likely to harm themselves. Some call the police officers who are set up to use lethal force when facing an intoxicated subject who is armed with a weapon.  When faced with lethal force, law enforcement is trained to use strategies to slow the scene and de-escalate whenever possible. Suicide by cop is a known phenomena. Family members frequently call the police when a family member arms himself with a firearm of knife expecting the police to simply disarm the subject. But in truth, the subjects actions are what guide police behavior not the other way around. Someone under the influence does not understand these principles and had they been unarmed and sober some might have been spared. No police officer ever wants this situation to become a reality.
REFERENCES
Essays, UK. (November 2013). On Being Sane In Insane Places. Retrieved from https://www.ukessays.com/essays/psychology/on-being-sane-in-insane-places-psychology-essay.php?vref=1 Taken July 26, 2018
Polizotti, L and Sefton, M (2018) The Police Chief’s Guide to Mental Illness and Mental Health Emergencies. Decision Press.

“Long haul cognitive effects of Covid-19” in those who have “recovered” Live zoom presentation by Whittier Rehabilitation Hospital – it was a lively event.

MICHAEL SEFTON

Thanks for those of you who signed on the last night’s webinar.  The Zoom presentation will be available at the Whittier Health website in the next couple weeks if interested. As we learned, even patients’ with mild infection can experience long lasting cognitive impact from the Covid-19 virus in the areas of memory, concentration, mental endurance, organization and verbal expression. There are mental health concerns as well that should not be overlooked.  Recovery from the virus can take weeks to months after the termination of treatment.  

The presentation on the impact of cognitive and behavioral functioning on ‘long haul’ cases is somewhat concerning given the 32 million Americans who have suffered with the virus. This is the second in a series produced by WRH and follows the November 2020 presentation on the psychological impact of the disease.  We will have a post here on the discussion from the webinar in the coming days.  The early studies have shown data from the population in Italy who have recovered from the virus in the first wave of the pandemic.

PTSD, biofeedback and preexposure training to lower impact of stress

PTSD is a known reaction to exposure to high stress, life threatening incidents that occur frequently in the careers of members of law enforcement. These are the high stress calls for service that leave a mark. They are the calls that wake you up at night and have the potential to become the traumatic events that can derail job performance. These are calls you think of when responding to an all units – referred to as a “code 3″ response in Maine during my tenure there. These are the calls that even when everything went well, the outcome turned out bad. And that is what is so debilitating and breeds cynicism.

Improving emotional regulation in the career first responder is a key element in officer well-being and career satisfaction. Biofeedback can be useful in shaping the body’s response to high stress calls. It involves decreasing certain brain responses to negative stimuli and is a critical skill for adaptive stress responses. Improved emotion regulation is associated with a decrease in amygdala hemodynamic activity following strongly negative stimuli providing researchers with a neural target that could be manipulated to improve emotion regulation.” Over the career of a law enforcement officer he or she can be expected to experience scores of traumatic calls sometimes more. Having a way to get out in front of the impact of such events using routine defusing or modified debriefing strategies can add to job satisfaction and officer resilience.

The cognitive model of PTSD suggests that the sense of current threat in individuals with PTSD is due to excessively negative appraisals of the trauma and a disturbance of memory of the trauma (Ehlers & Clark, 2000). Meichenbaum contends that SIT helps patients to “reauthor” their personal narrative of the trauma and focus on using coping skills to achieve treatment goals (Meichenbaum, 2019).

What is currently the best EEG intervention for mood and anxiety disorders — changing the alpha-to-theta ratio so that alpha activity is decreased relative to theta in the brain. Importantly, chronic exposure to traumatic scenes and a host of other factors can slowly elevate the sympathetic nervous system so that even routine police encounters can feel like a threat to officer safety and evoke a traumatic reaction.

A cardinal feature of patients with PTSD is sustained hyperactivity of the autonomic sympathetic branch of the autonomic nervous system, as evidenced by elevations in heart rate, blood pressure, skin conductance, and other psychophysiological measures. Accordingly, increased urinary excretion of catecholamines, and their metabolites, has been documented in combat veterans, abused women, and children with PTSD.  Sherin, 2011 Sherin, J, Newmeroff, C (2011). Post-traumatic stress disorder: the neurobiological impact of Psychological trauma. Dialogues in Clinical Neuroscience, September 13 (3)

“There is evidence that humans who are exposed to stress induces the release of dopomine in mesolimbic areas deep within the brain. The limbic system is the center for processing emotion and the minutiae of detail such as sites, smells, and the sound of raw pain and despair officers routinely encounter. These chemicals in turn could play a role in neuromodulation in the HPA axis that regulates the fight-flight mechanism in the brain. Whether or not dopamine metabolism is altered in PTSD remains conjectural, though genetic variations in the dopaminergic system have been implicated in moderating risk for PTSD” Sherin, 2011.

Particularly for stress management, targeting deeply located limbic areas involved in stress processing has paved new paths for brain-guided interventions. I have written about the neurobiology of police work in these pagesSix neurofeedback sessions resulted in significant improvements in measures of emotion regulation, including faster reaction times, in an emotion-regulation testing version of the classic Stroop paradigm. This finding indicates that participants got better at focusing on task-related information and ignoring irrelevant emotional stimuli. 

This finding indicates that participants got better at focusing on task-related information and ignoring irrelevant emotional stimuli. Furthermore, alexithymia scores (difficulties in cognitively processing emotion) were decreased relative to the participants’ score before training. Alexithymia scores increased in the control group of soldiers who did not receive any training, suggesting that the intervention prevented certain issues from developing according to Young, 2019.

What Is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

It is important to emphasize that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment. CBT is based on several core principles, including:
  1. Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
  2. Psychological problems are based, in part, on learned patterns of unhelpful behavior.
  3. People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives. Source: APA Div. 12 (Society of Clinical Psychology)

“Further, administration of the centrally acting β-adrenergic receptor antagonist propranolol shortly after exposure to psychological trauma has been reported to reduce PTSD symptom severity and reactivity to trauma cues.” Sherin, 2011 Stress inoculation is the best that first responders can hope for coupled with reliable self-care and mindfulness. _______________________________ Young, K.D. Neurofeedback for soldiers. Nat Hum Behav 3, 16–17 (2019). https://doi.org/10.1038/s41562-018-0493-2 . taken April 7, 2021

Meichenbaum, D. (2004) Stress Innoculation Training. Taylor and Francis.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345.

Keynan, J.N., Cohen, A., Jackont, G. et al. Electrical fingerprint of the amygdala guides neurofeedback training for stress resilience. Nat Hum Behav 3, 63–73 (2019). https://doi.org/10.1038/s41562-018-0484- 

Sherin, J, Newmeroff, C (2011). Post-traumatic stress disorder: the neurobiological impact of Psychological trauma. Dialogues in Clinical Neuroscience, September 13 (3)

Sefton, M (2019) The Neurobiology of Police Work. Linked In post May 2-2019

Coronavirus, behavioral health and the lingering impact on cognitive functioning in long haul covid recovered

In November 2020 we offered a virtual meeting on the Psychological Impact of Covid-19 after 6-8 months of quarantine and having schools and colleges closed to on campus activities. Professional, college, and high school sports were cancelled and teams were dealing with being in a bubble for the remainder of their seasons. Games were often postponed due to coronavirus exposure and contact tracing. It is now known that the virus has significant potential to impact all organ systems in the body – including the heart, lungs, kidneys and brain. For this post I am talking about the impact of long haul covid recovered cases of individuals who go on to experience cognitive symptoms for weeks or months. Whittier Rehabilitation Hospital has asked that SLP Lauren Guenon and I put together a presentation bringing to light what one might expect for those who are still having symptoms weeks later and what they can do about it.

There are potential long-term problems and short term issues people can expect when they are discharged from the hospital. I hope you will join us for the upcoming presentations that joins the Speech Language Pathology service and the Neuropsychological service in a hard look at the virus and it cognitive and psychological impact. Even people who had minimal symptoms and were never hospitalized are experiencing fatigue and “brain fog” as they get ready to return to work. They may be markedly debilitated and in need of rehabilitation like physical therapy, occupational therapy and now, we are seeing a need for cognitive rehabilitation provided by speech language pathologists and neuropsychologists alike. If you are interested in this topic or experiencing lingering symptoms, I hope you will join us either in person or on a live stream zoom event on May 20, 2021 at 7:00 PM.

Coronavirus

Below is a post from my Concussion Assessment website. It pertains to all that is cognitive. We are planning both an in person learning opportunity over lunch at our hospital and a live zoom event in later May 20, 2021 at 7 PM. If interested in this important topic please contact Joanne Swiderski at her email: jswiderski@whittierhealth.com

I look forward to meeting and hearing from a lot of the readers from here in Massachsetts.

Michael Sefton, Ph.D.

Domestic violence and the importance of red flag warnings for preventing homicide

Steven Lake murdered his family on
June 12, 2011 in Maine

Red flag warnings exist in most cases of domestic violence homicide. Just as in the case of Steven Lake, seen in his well-circulated arrest photograph, domestic violence has predictable consequences that afford law enforcement a window into the risk of escalating DV. By examining red flags, police have the opportunity to foresee the escalation of intimate partner violence. The timeline of domestic violence and the red flags that are present such as strangulation, any use of a firearm or forced sexual behavior are most common in the most high risk cases. The first given understanding is that DV is a secret, coercive and menacing problem that underlies many relationships, even those of law enforcement officers themselves. Advanced investigative prowess is crystal clear in hindsight. Lenore Walker has said that most family violence goes unreported and is cyclical. Police respond to the cycle after approximately 7 rounds of physical and emotional abuse when victims fear the safety of their children, according to Walker, a psychologist and expert on intimate partner abuse. When a potential victim is sure that her husband or family member will attempt to kill them than one may anticipate a higher level of risk than in a case of DV with physical abuse alone. The spontaneous disclosure of the expectation of death or being fatally beaten is a bold red flag – even higher than cases of pathological jealousy without mention of the fear of one-day being killed by a partner. Similarities exist such that tracking red flags will allow LEO’s on the scene to see for themselves the prevalent danger in many families and arrest men who are most abusive.  Having couples separate until cooler heads prevail does not work in lowering risk – in fact, it raises the level of danger in dysfunctional systems.

The police in Austin, Texas, here in the United States, are dealing with a horrific case of domestic violence homicide just this week in April 2021. A former Traverse County sheriff’s detective killed three members of his family while picking up his son for a monthly supervised visit. Stephen Broderick shot and killed his former wife, step-daughter and the girls boyfriend. He did this all the while he was coming to visit the 9 year old boy. Broderick fled the murder scene was captured 20 hours later. That Broderick was a police officer made this case of special circumstance.

The 16-year old child, who was among the victims, begged for a more restrictive supervision from her step-father who had been released from jail on lower bail and was not required to wear an ankle bracelet after a period of 3 months. The order of protection was brought against former police detective who was now unemployed. In spite of the protection order being in place, even the teen knew that orders of protection were often violated and difficult to monitor. It is reported that when victims believe that they will one day be killed by an intimate partner then the danger is real and should be considered a red flag. Having a child unrelated to the abuser In the household is another significant red flag. The analysis of any case of DV, that is heading toward a terminal event (domestic violence homicide), requires a careful review of symptomatic and behavioral research and observations of cumulative pre-incident indicators exhibited prior to the referenced homicides and suicide. In this case there was none offered.

“In the year that Amy Lake’s protection from abuse order was active against Steven, he violated that order at least five times but spent fewer than two days in jail for those violations, the report found. He also stalked her on Facebook, according to Diane Bowlby of the Bangor Daily News who was at the scene shortly after homicides.

Now nearly 10 years on, the psychological autopsy conducted in 2011, looked at the red flag warnings that are common to DVH everywhere. some I have described above. What brought my attention to the case in Maine was the purported prosecutorial impotence demonstrated by the district attorney Christopher Almy provided to local television. Almy said there was “nothing that could have been done” to protect the victim, Amy Lake and her two children, from her estranged husband Steven Lake. By saying there was nothing that could be done to protect the Lake family, the DA inadvertently undermined not only the police but the many agencies and medical professionals charged with drafting safety plans for victims of intimate partner abuse everywhere. In a similar way, newly elected county DA Jose Garza said he was “confident police did all they could to protect this family and he was incredibly proud of the officers” for the way they handled the Broderick case. More than one citizen comment in the newspaper questioned how anyone can be proud of a situation resulting in the deaths of 3 human beings? Given the outcome in both cases, and countless others, comments such as these strain credulity and fail to inspire.

On June 12, 2011, Mr. Lake snuck into the Amy’s rented home and staged a despicable murder scene ultimately killing the children he claimed to love while Amy was forced to watch. Ending with her shotgun murder and is own death by suicide – ending the Lake family timeline forever.

In an article on contingencies for bail in cases of domestic violence, attorney Nicole R. Bissonnette writes in the the Maine Law Review about the importance of thoughtful conditions of bail, especially among men who are found to have violated these conditions often by texting, stalking and using social media to intimidate and contact potential victims of extended family members. Her published paper adds that failure to relinquish all firearms must be reported to the federal database. Ms. Bissonnette cited our work over 12 times as it pertained to “red flag” warnings and bail reform. Bissonnette raised questions about protection orders and the need for added tools of enforcement for men who violate the protection from abuse orders (PFA) often called restraining orders.

In Maine, men who violate orders of protection are often released from custody with low bail or no bail. Steven Lake was twice released from jail on two thousand dollars that was paid by his father. We proposed increasing bail by a factor of ten on any violation of the stay away order and that a comprehensive review of possible high risk warning signs and psychological history be undertaken prior to release. Using a firearm in the commission of a domestic violence incident is defacto evidence of dangerousness and no bail shall be permitted until such time as all firearms are collected and a viable safety plan is in place for potential victims including police protection. The judiciary must sign on for this and understand the system of bail cannot be linear by assigning bail on the basis of criminal history alone.

The argument made by defense lawyers is invariably, that the lack of a criminal history defies precedent for holding men on large amounts of bail. This is illogical given the numerous red flags that were present in this case and Lake’s disregard for the law. In truth, Mr. Lake had never been arrested for his history of sexual crimes during the marriage, verbal threatening or anything until his final meltdown began. Tension boiled over on June 14, 2010, at the family home at 9 Brighton Road in Wellington when Steven allegedly brandished a gun in front of his family, threatening Amy and the man he accused her of having a relationship with, as reported in the Bangor Daily News. After that event, he was arrested and charged with criminal threatening for which he was heard to say that “he would never serve a day” in jail and that “the price of divorce is 28 cents – about the cost of one bullet.”  A comment that a court appointed psychologist might have wanted to better understand.

Lake slept with a pistol and holster hanging on his bed post. He posed with a rifle in his high school year book.  Steven was a gun guy and owned over 20 firearms. The criminal threatening occurred one year before he killed them all as the trial for criminal threatening approached and as the countdown to his divorce from Amy began ticking louder in his brain. None of his weapons were inventoried by police. Had he been held on high bail for each of the PFA violations and been properly assessed for his proclivity toward violence, he would have been unable to kill them one year down the road in 2011. Yet he had time to scribble over 10 suicide notes blaming everyone but himself for the deaths including the judge and his father-in-law, whom he promised to “see in hell.”  His father told us for the final report that if the judge had only let Steven see his 2 children for the 8th grade celebration, this could have all been avoided. Like his son, the senior Mr. Lake looked to redirect blame away from his son. Aside from visiting the school where Amy taught, the 2 hours we spent with Steven Lake’s parents were perhaps the most unsettling and sad of the nearly 200 hours and over 60 people who agreed to be interviewed. 

Fast forward 10 years. The setting is north central Texas. On Sunday morning April 18, 2021, in northwest Austin, law enforcement officials say Stephen Broderick shot and killed his step-daughter, Alyssa; her mother and his estranged wife, Amanda Broderick, 35; and Alyssa’s boyfriend, Willie Simmons III, 18. The 9 year old biological child was not harmed. 

images
Stephen Broderick booking photo 2021

It is common for former intimate partners troll the social media accounts of family members in an effort to locate estranged spouse and her children who may be in hiding. Both Amy Lake and Amanda Broderick, the Texas mother of 3 expressed an interest in having children remain in contact with extended family, in spite of pending felony charges. Amy was keen to have her children see their grandparents (Steven’s parents) and have supervised visits with Steven.  A continuum of interagency cooperation is needed to effectively measure risk and understand the pre-incident red flags that are common manifestations of abuse and often forecast terminal violence, all of which occurred in the 2 cases in this report. As the totality of these red flags comes into focus it becomes incumbent upon each of us to take action on behalf of those most at risk just as we are mandated to do in cases of child and elder abuse. Amy communicated with her in-laws regularly via social media showing photos and posting life without Steven that he saw while trolling her account. In a similar way, Amanda Broderick wanted her son to maintain contact with his father Stephen.

Meanwhile, Ms. Broderick was said to have been sent over 30 text messages with a variety of intimidating sentiments about the upcoming trial yet she okayed supervised visits with their son, age 9. Any contact like this is a violation of the protective order and should have landed Broderick in jail. And they were sure to open up possible access to the jealous perpetrator to clues about current living arrangements, employment, after school activities, and other potential clues that raised the risk of further domestic violence and ultimately DVH. There were messages of deep felt sorrow and remorse as well, that are common in the cycle of abuse.

While awaiting adjudication of felony charges there must be no contact between children and violent perpetrator whatsoever. In Austin, the victim expressed a wish to allow her estranged husband to have contact with the little boy – his son, in spite of pending felony rape charges brought forth by the 16-year old step daughter who rightfully feared for her life. Amanda Broderick saw this as being in the “best interest of the child”. This remains a weakness in the overall safety plan and should have been denied by the family court.  It was unjustified given the fear expressed by the victims in this case, which ultimately were quite valid.

Firearms are a major cause of DVH and in every state are required to be taken from men with active protection orders in place. This was the default expectation in the two cases described here but in the case of Stephen Lake his arsenal of 22 firearms were not removed from his possession in spite of court orders. Similarly, the Austin killer was left with at least one firearm used to kill his family. Lake left 9 suicide notes many of which were rambling, angry tirades toward his wife and in laws. The Austin killer did not take his own life and was captured raising the specter of possible psychological analysis of his motives making the two cases very different at this level. To what extent Texas authorities will endeavor to understand the events that preceded the murders remains unclear. However, gaining a comprehensive understanding of the red flag warnings in this case is highly recommended and will add to the body of literature on domestic violence.

A court-sanctioned visitation agreement required them to maintain some contact to allow Broderick time with his son. In the application for a protective order, Amanda wrote that Broderick called her some 30 times after she left home to intimidate. She feared he would come after her and the children, she said, “because these allegations have come out and he may lose his career.” He could be dangerous, she warned. So why was the visitation permitted in the order of protection?

Why would a court order that an abused family be required to allow an accused rapist to have visits with a 9 year old child? It cannot be in anyone’s best interest to have forced visitation with a suspected violent and angry abuser. Did no one grasp these red flags? 

One could argue that the killer in Austin, Steven Broderick shared most commonalities with the Maine case ten years previously, including sexual violence, coercion, threats of death, pathological jealousy, violation of the order of protection, trolling social media and refusal to surrender his firearms. He was a cop. Broderick was a SWAT trained police officer who resigned his position after being arrested for sexual assault on his step daughter. He should not have had a firearm pending the outcome of his case. He was released from jail on partial bail because he did not have the funds for the bail that was set by the court. He should not have been permitted to visit with his biological son. The risk of violence as was easily foreseen given past behavior. In the same manner, Stephen Lake would never stand trial, and had a cheap divorce in mind early on. 

“Domestic violence is not random and unpredictable. There are red flags that trigger an emotional undulation that bears energy like the movement of tectonic plates beneath the sea.” according to Michael Sefton (2016).

  1. Threatens to kill spouse if she leaves him – pathological jealousy
  2. Actual use of firearm or other weapon anytime during domestic violence incident
  3.  Access to firearms even if he never used them – veiled threats
  4. Attempt at strangulation ever during fight
  5. Forced sex anytime during relationship
  6. Unemployment of perpetrator
  7. Stalking via social media
  8. Presence of unrelated “step”child in home
  9. Spouse finds new relationship soon after separating
  10. Low bail release from custody – high bail holds are essential in DVH mitigation

If you or someone you know is facing domestic violence, call the National Domestic Violence hotline for help at (800) 799-SAFE (7234)

Sefton, M. (2016) Blog post: DVH in MA: 4 year old child begs his father.  https://msefton.wordpress.com/2016/10/02/dvh-in-ma-4-year-old-child-begs-father-not-to-murder-his-mother/. Taken 4-25-2021

Allanach R. et al., (2011). Psychological Autopsy of June 13, 2011, Dexter, Maine Domestic Violence Homicides and Suicide: Final Report 39 (Nov. 28, 2011), http://pinetreewatchdog.org/files/2011/12/Dexter-DVH-Psychological-Autopsy-Final-Report-112811-111.pdf.

Michael Sefton

What are we learning 12 months on?

During the pandemic, mental hygiene has become just as important as hand washing. It’s time to disinfect your thoughts and kill the ANTs. As we move into year number two of the pandemic it has become clear that some American’s may be falling victim to automatic negative thoughts or ANTs.
During the pandemic, mental hygiene is just as important as hand washing. It’s time to disinfect your thoughts and kill the ANTs to overcome anxiety, depression, trauma, and grief. ANT is an acronym for —Automatic Negative Thoughts. Daniel G Amen, MD 2020
Over one year into the pandemic while only 50 % of the US population is currently vaccinated with at least the first shot, we are seeing the importance of mental health in managing the pandemic. It is now abundantly clear, that it is because of mental health underpinnings, that the next wave of the pandemic is building. People cannot remain in isolation forever. The indefinite duration of confinement grew insurmountable to enforce and the collective civility toward social distancing and mask wearing became politically untenable for many governors.  People need to socialize, be free to worship, attend weddigs and funerals, even dance in the streets, as we have seen Americans do ever since it “reopened” when state governor’s decried the pandemic under control. And we have paid the price for this. Mental health tends to be the ugly step-child of physical illness in a society that is strongly biased against the emotionally infirm in favor of the medical model of well-being. For one thing, alcohol sales increased 200 percent among Americans coping with loneliness and frustration while in quarantine. There is no doubt that people felt the stress of being cooped up during the first weeks of the pandemic. The quarantine put a strain on sensible behavior and emotional credulity over social distancing, all the while putting ANTs in our heads. In places like India and across Europe where the vaccine roll out has been less successful the infection rate has risen, and given the propagation of variants that have been reported, those who are not yet vaccinated have much to fear. Michael Sefton

Cardiac Arrhythmia and reducing health risk using biofeedback

Methods that reduce autonomic innervation or outflow have been shown to reduce the incidence of spontaneous or induced atrial arrhythmias.26 The latter studies suggest that neuromodulation may be helpful in controlling atrial fibrillation.

Chen et al. (2014) published a review of the relationship between the autonomic nervous system and the pathophysiology of AF and the potential benefit and limitations of neuromodulation in the management of this arrhythmia that is beyond the scope of this paper.

I am optimistic that the neuroregulation derived from EEG neurofeedback may be a mitigating treatment for both autonomic dysfunction and greater self-regulation and abstinence from substance use. The role of the autonomic nervous system in atrial fibrillation is multifactorial and alcohol induces atriogenic changes are powerful – including the potential for cardiac remodeling. “Autonomic nervous system activation can induce significant and heterogeneous changes of atrial electrophysiology and induce atrial tachyarrhythmias, including atrial tachycardia and atrial fibrillation (AF).” The importance of the autonomic nervous system in atrial arrhythmogenesis is also supported by circadian variation in the incidence of symptomatic AF in humans in Chen et al., 2014. I am working on a protocol using biofeedback and mindfulness to mitigate the autonomic underpinnings of arrhythmias in hope of making a positive impact on recovery from AF-related stroke. There is a peer reviewed literature for using neurofeedback for reducing the craving for alcohol that may be matched with paced breathing and heart rate variability which can activate parasympathetic pathways and modify baroreceptor response and its multifactorial impact on health described in this paper.

References

Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available at: http://www.samhsa.gov/data. Accessed January 25, 2021

Steinbigler, P Haberl, R. König, B. et al. (2003) P-wave signal averaging identifies patients prone to alcohol-induced paroxysmal atrial fibrillationAm J Cardiol, 91, pp. 491-494

Voskoboinik, A et al. (2016). Alcohol and Atrial Fibrillation: A Sobering Review. J of Amer College of Cardiology, Volume 68, Issue 23, 13 December 2016, Pages 2567-2576.

O’Keefe, J, DiNicolantonio, D.J. Alcohol and Atrial Fibrillation Journal of the American College of Cardiology, Volume 69, Issue 20, 23 May 2017, Pages 2578

Chen, P, Chen, L, Fishbein, M, Lin, S-F, and Nattel, S (2014). Role of the Autonomic Nervous System in Atrial Fibrillation: pathophysiology and therapy. Circulation Research, Volume 114, Issue 9, 25, Pages 1500-1515

Viskin S, Golovner M, Malov N, Fish R, Alroy I, Vila Y, Laniado S, Kaplinsky E, Roth A. (1999). Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10,000 episodes. Eur Heart Journal; 20:1429–1434.

Law enforcement suicide: Using the psychological autopsy for questions of line of duty deaths

Two Capitol police officers have taken their own lives since the insurrection at the U.S. Capitol on January 6, 2021. This information came after the two officers spent 5 hours fighting the insurrectionists sometimes in hand to hand combat. Jeffrey Smith, a D.C. Police officer, and Capitol Police Officer Howard Liebengood both “took their own lives in the aftermath of that battle” according to an article in Politico on January 27, 2021. A third officer, Brian Sicknick died during the insurrection and his manner of death has not yet been officially determined. Some reported seeing Officer Sicknick being struck in the head with a fire extinguisher during the riot.

First responder suicide is generally not considered a line of duty death and as such, fails to yield the honor given to officers who die in shoot outs or other direct line of duty incidents. And deaths by suicide do not bring family members the death benefits they deserve. Two police officers have died by suicide after confronting rioters at the Capitol that were sent by Commander in Chief Donald Trump. This fact was brought forth by House Impeachment Managers during Trump’s second impeachment trial recently completed.These men must be afforded the honor and benefits provided to any surviving spouse of a line of duty death because that is why these men died. 

The juxtaposition of these facts cannot be ignored. Every one of the hundreds of police officers put their lives on the line as a result of the former president’s truculent narcissism. It would be a dishonor to the men who gave their lives by denying this causal underpinning of their deaths. Suicide by law enforcement officers exceeds the number of officers who die in in gun fights, car accidents, on-duty heart attacks, attacks by citizens, calls for domestic violence, and other police calls for service. “This fact thrust these most private of acts into the national spotlight and made clear that the pain of Jan. 6 continued long after the day’s events had concluded, its impact reverberating through the lives removed from the Capitol grounds” as written in a recent Washington Post report. 

There are things that must be done when law enforcement officers die as a direct result of the the calls they take and the trauma they experience that directly results in their death. Neither of these officers would have died if they had not jumped into the crisis taking place at the U.S. Capitol. Both men were solid members of the Capitol and Metropolitan Police Departments and had no history of behavioral health claims. A transparent psychological autopsy would show the factors that triggered the terminal events leading to each man’s death. For their part, members of Congress spoke highly about the three police officers who died as a result of the riot.

In the days that followed, Erin said, her husband, Capitol officer Jeffery Smith seemed in constant pain, unable to turn his head. He did not leave the house, even to walk their dog. He refused to talk to other people or watch television. She sometimes woke during the night to find him sitting up in bed or pacing. Her husband was found in his crashed Ford Mustang with a self-inflicted gun shot wound that occurred on his way to the job.

Peter Hermann Washington Post 2-12-2021

Rioters swarmed, battering the officers with metal pipes peeled from scaffolding and a pole with an American flag attached, police said. Officers were struck with stun guns. Many officers were heard screaming into their radios “code-33” the signal for “officer needs help” and usually a signal bringing an “all hands” response to the scene of the emergency. Situations like this send chills down the spine of officers responding to calls for help – some are injured in car crashes racing to back-up officers in danger. It is always hoped that when the call for help goes out that there will be enough manpower to push back on the crowd, however large. In this case, the crowd far exceeded the number of LEO’s available for duty. 

 The psychological autopsy is a single case study of a death event that serves to uncover the psychological causes of death. This study would answer these questions and establish an understanding of worst case scenario of frontline exposure to trauma and possibly offer insight into underlying history that may have been anticipated and stopped. When law enforcement officers take their own lives this careful analysis of the hours and days preceding their time of death is essential. “From this information an assessment is made of the suicide victim’s mental and physical health, personality, experience of social adversity and social integration. The aim is to produce as full and accurate a picture of the deceased as possible with a view to understanding why they killed themselves.This would answer the question as to whether or not the deaths may be considered to be line of duty, as they must. Psychological autopsy is probably the most direct technique currently available for determining the relationship between particular risk factors and suicide” Hawton et al. 1998

I have proposed a Behavioral Health initiative in conjunction with changes in police policy and transparency that has been the central posit of social clamor since the death of George Floyd this summer. The International Association of Chief’s of Police (IACP) has a broad-based Mental Wellness program it is reporting on its website that highlights the importance of this kind of support. “The IACP, in partnership with the University of Pennsylvania (Penn) and the Bureau of Justice Assistance (BJA)’s VALOR Initiative, is customizing a program specifically designed to help officers and agencies by enhancing resilience skills. The cost of such a program will reap rewards in the form of career longevity, officer well-being, officer morale, quality of community policing, and greater faith and trust in law enforcement in general.

This investigation is an individually designed case study that elicits a broad range of factual data regarding the antemortem behavior of a decedent in the immediate day or days leading up to the suicide. In this case, what are the events that transpired in the days before the two Capitol police officers took their own lives? The fact is that both men were exposed to incidents and participated in protecting the Capitol on January 6, 2021. Both men were engaged in hand to hand combat.  It is known that the insurrection resulted in the death of a fellow officer and the deaths of 4 other people engaged in violent mayhem in which these men and hundreds others may have been killed. Both men believed the insurgency was potentially deadly to them or their fellow officers. The psychological autopsy is especially important when first responders and essential workers are involved and die soon after. When LEO’s and first responders are put in fear of death or see other officers being placed in the direct line of fire, are vastly outmanned, and have no way in which to stop an attack, they are at high risk for the “hook” that comes from an acute stress reaction and over time, becomes a monkey on the backs of so many fine men and women.  Michael Sefton, Ph.D. 2018 Direct Decision Institute, Inc.


Hawton, K., Appleby, L., Platt, S., Foster, T., Cooper, J., Malmberg, A. & Simkin, S. (1998). The psychological autopsy approach to studying suicide: a review of methodological issues. Journal of Affective Disorders 50, 269–276.

IACP (2021) Officer Resilience Training Conference https://www.theiacp.org/projects/law-enforcement-agency-and-officer-resilience-training-program, Blog post taken February 13, 2021