High-profile plagiarism scandals have become too routine of late; a sign of the current rapid-fire internet-driven media world, where it’s easy to cut and paste (and just as easy to detect cutting and pasting). One recent victim has been Sen. John Walsh (D-MT) who dropped out of his Senate race due to the allegations. A twist to his controversy involved his campaign aide’s remarks in July that post-traumatic stress disorder (PTSD) may have contributed to Walsh’s plagiarizing parts of his U.S. Army War College Master’s thesis in 2007.

Walsh’s aide initially released information about a fellow Iraq War veteran and friend committing suicide shortly before the paper was written; Walsh then admitted to undergoing treatment and being on medication. He initially went along with his aide’s implications, saying, "I don't want to blame my mistake on PTSD, but I do want to say it may have been a factor…My head was not in a place very conducive to a classroom and an academic environment." Tellingly, Walsh later backtracked on the implications of his aide’s remarks, saying in a subsequent KMMS radio interview that “I am in no way—no way—tying what I did to any type of PTSD…That is not in any way what I meant or said.”

Usually, as a psychiatrist, I would praise someone for being open and forthcoming about their psychiatric diagnosis and treatment with the public, especially given the ongoing societal stigma towards mental illness and psychotropic medication. Barbara Van Dahlen even editorialized in Time on July 25th (http://time.com/author/barbara-van-dahlen-2/) that this disclosure was a “silver lining” because it opened more dialogue about mental health and its consequences. A psychologist, she even conjectures that there is a possible cause and effect relationship between PTSD and plagiarism due to “possible impairment…[in] cognitive and emotional functioning.”

However, in this instance, I find her conclusions naïve and even dangerous. In Sen. Walsh’s case, I felt the same initial annoyance and suspicion as many others (especially veterans http://www.washingtonpost.com/news/checkpoint/wp/2014/07/25/opinion-sen-john-walsh-citing-ptsd-in-defense-of-plagiarism-hurts-veterans/) that someone was making excuses for their bad behavior, and even more shamefully so, by using the “noble” cover-up of being someone suffering from mental illness. If anything, skepticism and an increase in stigma might result from people abusing their diagnoses to excuse poor behavioral choices, because others will wonder if those truly suffering from mental illness are just crying wolf.

This controversy points to a larger issue. There is an ongoing blind spot in psychiatric diagnosis, one that remains complex and difficult to resolve. It is the question of moral awareness and how neurobiology interacts with free will. Forensic psychiatry continues to explore that intersection between criminality and insanity; in courts, defendants are assessed for their capacity to understand between right and wrong, and/or whether their behavior stems directly from their mental illness.

The answers are not always cut and dry. If someone is responding to their hallucinations or delusions, are they still culpable for killing or attacking someone? If someone is acutely manic, are they to blame for their disinhibited behavior, such as massive spending sprees, driving out of control, cheating on their spouses due to hypersexual impulses?

Further complicating the picture is the overlay of what mental health professionals call personality disorders, or also often casually called “Axis II” as found in the DSM (Diagnostic and Statistical Manual of Mental Disorders) multiaxial system of diagnostic assessment. Controversial but crucial, personality disorders are defined by DSM as “enduring maladaptive patterns of behavior, cognition, and inner experience…These patterns develop early, are inflexible and are associated with significant distress or disability.” Some of the traits associated with personality disorders have entered our everyday lexicon with usually negative connotations, such as narcissism, dependence, and the notorious antisocial personality, aka sociopath or psychopath.

Despite occupying a huge section of psychiatric diagnosis and assessment, it has been difficult to assign a clearcut neurobiological etiology to these personality conditions, and oftentimes, environmental and childrearing practices are considered strong contributors to their development. (During the leadup to the newest edition of DSM, DSM-5, which was just released last year, some DSM committee members even argued that personality disorders ought to be eliminated or have fewer categories.)

There have been some studies noting specific brain changes and findings to people with antisocial personality disorder (PD), indicating a possible biological-genetic basis behind lack of empathy or emotional coldness. Impulse control and behavioral issues also remain controversial; some argue that there are genetic and neurobiological changes and findings that make one prone to poor impulse control and disinhibition (or even the opposite, overcompulsiveness as with obsessive-compulsive disorder) or addictive behaviors like alcoholism and substance abuse, or pathological gambling. Others feel that those behaviors mainly stem from bad parenting, trauma and/or lack of discipline during formative childhood years.

In the case of plagiarism, one might compare it to the phenomenon of pathological or compulsive lying (aka the fanciful terms mythomania or pseudologia fantastica). Although not considered its own official disorder, pathological lying has been associated as a symptom of some personality disorders and also the general category of factitious disorders, where people lie about having physical or psychological symptoms, but do so for unconscious motivations (such as enjoying the attention given to a sick person or victim) and not so much for actual personal advantage. There is also plain old malingering, where people lie for secondary gain, quite consciously, whether for extremes like fame, business, and politics, or to just get admitted to a warm hospital bed for food when one is homeless.

There isn’t any research literature about plagiarism as an associated symptom of any mental disorder, aside from the mysterious phenomenon of cryptomnesia, or unconscious plagiarism, where people attribute forgotten external memories to an original thought process. People might mistakenly think they came up with a random quote or idea, and have forgotten that they read or overheard it. Studies show these mistakes are not uncommon, and might be viewed as a memory error condition. According to Amanda Gingerich and Meaghan Sullivan’s October 2013 article in the Journal of Cognitive Psychology, these errors happen under times of cognitive duress or under the circumstances of social interaction and idea generation, where monitoring the source of one’s ideas becomes fuzzy.

But cryptomnesia is considered unintentional and usually brief and momentary in scope, unlike the elaborate and orchestrated copying of verbatim passages and cobbling of information found in the recent plagiarism scandals involving Sen. Walsh or recently fired Buzzfeed editor Benny Johnson, or the older scandals with fired New Yorker writer Jonah Lehrer, fired New York Times reporter Jayson Blair, and fired New Republic writer Stephen Glass (who took things a step further by presenting fiction as fact.)  (Fareed Zakaria remains oddly immune as yet to recent extensive plagiarism charges against him.)

Blair’s case remains a particularly riveting tale, and one that illustrates the moral chicken-or-egg conundrum of his alleged bipolar disorder and past substance abuse affecting or not affecting his brazen behaviors. These behaviors included inventing quotes and scenes from people he never met and places he never saw, and grabbing bits and pieces from other people’s articles. Only his own psychiatrist may know the truth behind whether Blair was a tragic victim of his untreated condition, or a clever manipulator grabbing at straws. Interestingly, Blair himself (who now works as a life coach) recently stated in a May 2013 Ellicott City Patch interview with Andrew Metcalf that his past behavior was due to “character issues” and not his bipolar disorder.

As a psychiatrist, I do not believe primary mental illnesses (aside from the aforementioned personality disorders) cause plagiarism. Plagiarism involves an internally logical thought process, a steady hand carefully putting together portions of copied information in a linear fashion; the product pretends to be an original completed written piece. Plagiarism is difficult to detect without someone directly pointing out the absent attributions and copied words.

It seems atypical to me for this deliberate, planned, coherent act of writing to be associated with the thought disorder and flight of ideas and ramblings of someone in the throes of acute delusional psychosis or florid mania. It is also atypical of the creativity and originality well-known to be associated with some people with mood disorders (including famous artists and writers), who tend to have no trouble coming up with their own ideas and material, and if anything, seem the least likely types to merely copy someone else’s work.    

There is also the secondary gain factor, which is quite high with plagiarism. These recent perpetrators achieved extraordinary success, fame, book deals, and prestige. Until the perpetrators were caught (or in Zakaria’s case, even in spite of being caught), they must have known these potential and realized rewards.

Could there be some sort of illicit addictive high involved with the transgressive act of plagiarism or fabulism? Possibly. Does that indicate some sort of disinhibition or impulse control disorder caused by another underlying mental illness, not unlike the addictive rush and impulsivity associated with kleptomania? It is difficult to say, but again, the words themselves are somewhat damning. Stealing and gambling and sexual addiction are more quick, sudden, repetitive activities. Whereas plagiarism is a more carefully planned endeavor, not unlike putting together a neatly tiled floor out of fake marble and passing it off as the real deal. Plagiarism can approach the cognitive intensity of writing itself (although of course, it’s easier--you’re just copying large chunks.) It still takes a sharp mind to smooth out the edges and make plagiarized pieces sound good enough to fool tons of top editors and readers. A mind that doesn’t really seem broken to me, even if the moral conduit behind it is.

So I am pleased to see Sen. Walsh backtracking from his initial halfhearted PTSD explanation; there may be hope for him yet. And I hope that people keep an open mind when it comes to the intersection between criminal behavior and mental illness; there are complex examples of injustices occurring on both sides of the argument. (Several people in jail suffer from true mental illness and are improperly funneled into the criminal justice system, and conversely, several criminals trying to avoid jail end up hiding out in psychiatric hospitals.)

In the case of plagiarism, one would have to look more closely at the personality disorder spectrum of psychiatric diagnoses (particularly antisocial and/or narcissistic behavior) and decide from there whether the behavior is part of a longstanding pattern, or a one-time mistake done in a moment of moral weakness or temptation (like a kid with perfectionistic parents who is stressed out about a homework assignment.) But I would not give anyone carte blanche to easily blame plagiarism as a symptom of mental illness. Such attribution devalues those who do suffer with true mental illness and misinforms the public accordingly. Bad behavior is far too complicated for such a simple excuse. 

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