Essay#3 English Class.

Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006) DOI: 10.1002/cbm R1 Female serial killing: review and case report Criminal Behaviour and Mental Health16: 167–176 (2006)Published online 13 July 2006 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbm.615 ANDREAS FREI 1, BIRGIT VÖLLM 2, MARC GRAF 3 AND VOLKER DITTMANN 3,4, 1Forensic Psychiatric Services, Psychiatric Hospital Lucerne, Kantonsspital, 6000 Lucerne, Switzerland; 2University of Manchester, Neuroscience and Psychiatry Unit, Manchester, UK; 3Forensic Psychiatric Department, University Psychiatric Services, Basle, Switzerland; 4University of Basle, Switzerland ABSTRACT Background Single homicide committed by women is rare. Serial killing is very infrequent, and the perpetrators are usually white, intelligent males with sadistic ten - dencies. Serial killing by women has, however, also been described.

Aim To conduct a review of published literature on female serial killers and consider its usefulness in assessing a presenting case.

Method A literature review was conducted, after searching EMBASE, MEDLINE and PsycINFO. The presenting clinical case is described in detail in the context of the literature findings.

Results The literature search revealed few relevant publications. Attempts to catego - rize the phenomenon of female serial killing according to patterns of and motives for the homicides have been made by some authors. The most common motive identified was material gain or similar extrinsic gratification while the ‘hedonistic’ sadistic or sexual serial killer seems to be extremely rare in women. There is no consistent theory of serial killing by women, but psychopathic personality traits and abusive childhood experiences have consistently been observed. The authors’ case did not fit the descrip - tion of a ‘typical’ female serial killer.

Discussion In such unusual circumstances as serial killing by a woman, detailed individual case formulation is required to make sense of the psychopathology in each case. Publication of cases in scientific journals should be encouraged to advance our understanding of this phenomenon. Copyright © 2006 John Wiley & Sons, Ltd.

Introduction Overall, men are about six to seven times more likely to kill others than are women (d’Orban, 1990; Kellermann and Mercy, 1992) but this ratio is different for homicide in a domestic environment. Trube-Becker (1982) found that in 23% Frei et al.

Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006)DOI: 10.1002/cbm R1 168 of cases of spouse-killing the perpetrator was a woman. These women have usually suffered long periods of abuse by their partner (Mercy and Saltzmann, 1989; Trube-Becker, 1982). This type of killing can be reconciled with the percep - tion of women as nurturing and vulnerable, and only capable of extreme violence if provoked. Serial homicide does not fit this stereotype. Serial killing has been defined as three acts of killing within a time span of at least 30 days (Holmes and Holmes, 1998). Among men, the killing is generally committed by one person with no prior relationship to the victim. The FBI has devised an offender dichotomy into organized or disorganized types based on crime scene characteristics (Schurman-Kauflin, 1999). Further classification attempts have been made by Holmes and Holmes (1998) according to geographi - cal location, methods of murders, victim types, motives and anticipated gains.

They suggested a classification into visionary, mission-orientated, hedonistic and the power/control killer. The extent to which findings in male samples can be extrapolated to women is unclear. Presented with a requirement to assess a woman who had killed twice and narrowly missed doing so on at least one other occasion, our aim was to review the literature on serial killing by women and evaluate the extent to which the presenting woman fitted a recognized type. The woman gave full and free consent to her story being used in this piece of work, although we have changed some unimportant details in order to protect her identity.

Literature review Method A literature search of EMBASE (1980–2004), MEDLINE (1966–2004) and PsycINFO (1967–2004) using the search terms ‘female’, ‘serial’, ‘multiple’, ‘killing’, ‘killer’, ‘murder’, ‘homicide’ and ‘manslaughter’ was conducted and relevant cita - tions identified. Reference lists of the literature obtained were searched for further material.

Results Our searches identified only 15 relevant citations. Of those, four were disserta - tions, two monographs, five scientific papers (one specifically focusing on homi - cide charges against nurses, one on mass murder in the domestic context) with original data, one editorial and one book review. Two authors described the case of Aileen Wuornos or the movie Monster , which is based on her case. We excluded citations that only report single cases or focus on specific groups of offenders (e.g. nurses) or particular psychopathological aspects (i.e. gender iden - Female serial killing Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006) DOI: 10.1002/cbm R1 169 tity), the editorial and book review and will describe the remaining seven reports in more detail. Except for one dissertation (Schurman-Kauflin, 1999) these reports do not include interviews with the female offenders. Hickey (1986), based on American crime statistics, described a female/male gender ratio of one to six, similar to that described for ‘ordinary’ homicides (d’Orban, 1990; Kellermann and Mercy, 1992). In 1997, the same author studied 34 cases of US female serial killers active between 1795 and 1988, half of whom had a male accomplice. The average age of these women was 33 years and six were nurses. In about three-quarters, material gain seemed to have been one motive. Poisoning was the most common method of homicide and most women had killed people they knew. Wilson and Hilton (1998) analysed 105 female serial killers, using at least two independent sources to confirm cases. The preferred means of killing was poison - ing and in these cases the time between the first killing and apprehension was longer than when other methods of killing were used. Kelleher and Kelleher (1998) studied a series of 86 American cases and found that the victims were most commonly children, the elderly or spouses. Those women, classified as ‘black widows’, had the longest active period – over 10 years – in contrast to male serial killers, who tended to roam. Holmes and Holmes (1998) found that female serial killers were ‘geographically stable’ and lived in the same area where they committed their offences. Holmes and Holmes (1998) tried to categorize female serial killers. They described five types according to motives and pattern of offences (Table 1). The ‘comfort killer’ tended to be the most prevalent and included cases of killing a series of husbands (‘black widow’). The ‘hedonistic’ type was rarely observed in women. Examples of the ‘power seeker’ type were women in caring professions (‘death angels’). Kelleher and Kelleher (1998) proposed a slightly different classi - fication into ‘black widow’, ‘angel of death’, ‘sexual predator’, ‘revenge’, ‘profit or crime’, ‘team killer’, ‘question of sanity’, ‘unexplained’ and ‘unsolved’. They found the highest prevalences for ‘team killer’ (28%) and ‘black widow’ (26%). One thing that female serial killers have in common with their male coun - terparts is that no one theory can explain the phenomenon. Explanations that have been put forward overlap with those for single homicide and other violence and include biological/genetic, psychological and social factors (Holmes and Holmes, 1998; Papazian, 2001). The question is why these people kill more than once when, in general, homicide is not a recidivist crime. It has been speculated that positive reinforcement might drive future offences (Scott, 1996). Psychopathic traits and grossly abusive childhood experiences have consistently been described in male and female serial murderers (Schurman-Kauflin, 1999). An important role of a ‘private internal world’ of violent fantasies has also been suggested (Burgess et al., 1986). The concept of ‘displaced aggression’ has also been raised (Mitchell, 1997) and may be helpful in understanding victim choice. Frei et al.

Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006)DOI: 10.1002/cbm R1 170 Case report PK was referred to the Forensic Health Services of a large Middle European town in 1998. She was remanded in custody for assaultive behaviour, threats to police officers and suspicion of arson.

Family history PK’s father was a carpenter, her mother an unskilled domestic. There was no family psychiatric or forensic history, although both parents abused tranquillizers.

Personal history PK was born in 1973. She was an only child and was brought up in a rural area.

The birth was unremarkable and milestones normal. We could not find any history of sexual or physical abuse. She showed signs of conduct disorder and displayed severe temper tantrums from the age of three onwards. PK said she felt affection for family pets, but tortured snails and insects. She described the most Table 1: Types of female serial killers Type Characteristics Visionary • Severe break with reality, e.g. delusions and hallucinations • Motivation extrinsic to the personality, i.e. response to auditory hallucinations or delusional beliefs • Attacks tend to be spontaneous • Victim selection driven by psychopathological symptoms, random and non-specific, usually strangers Comfort • Motivation extrinsic, e.g. material gain • Acts tend to be well planned and organized • Victims previously acquainted with the offender and specifically selected according to the expected gain Hedonistic • Motivation intrinsic, e.g. sexual gratification, sadism • Acts tend to be planned and organized • Victims are strangers, often with specific characteristics Power seeker • Motivation intrinsic, i.e. domination of another person • Acts tend to be planned and organized • Offender might use offence to boost self-esteem • Stranger victims with specific characteristics, e.g. helplessness Disciple • Killing occurs under the influence of a charismatic leader • Motivation intrinsic, i.e. personal acceptance by her ‘idol’ • Acts tend to be planned and organized • Victim selected by leader (usually male), often strangers Female serial killing Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006) DOI: 10.1002/cbm R1 171 traumatic event of her childhood as the death of the neighbour’s dog. PK hated her parents for being weak, abusing drugs to cope and for not punishing her when she ran away at the age of 12. From 1980 to 1988 PK attended mainstream schools, where she felt like an outcast and was bullied. In her teens she played ‘mean jokes’ against neighbours and went shoplifting. After school, PK worked for a year as an au pair. She reported humiliation and sexual harassment by the man of the family she worked for. In 1990, she was apprenticed as an office clerk, although she said she wanted to be a police officer; she did not cope with office work and was dismissed after physically attacking a waitress. In 1991, she started an apprenticeship as a shop assistant and in 1995 one as an electrician. PK described herself as loner; her favourite spare-time activity was long bicycle rides. She had a relationship, possibly platonic, with a police officer 20 years her senior. In 1995, PK had a relationship with a man who was fascinated by the Nazi and Taliban ideology and introduced her to the use of weapons and Aikido. She had no history of alcohol or illicit drug misuse.

Forensic psychiatric history 1991 PK began fire setting and making anonymous telephone calls to the police. She was arrested several times carrying an illegal ‘stiletto’ knife.

PK decided to seek psychiatric help, but immediately began to stalk and threaten the therapist. PK reported that she travelled to a nearby town several times a year to ‘stalk’ and ‘terrorize’ women, all strangers. On the day of her first homicide she had threatened two other women before she stabbed her unknown female victim to death as she returned to her car. These offences only came to light with her later confession. 1992 After multiple charges of arson, a pre-trial report by a prominent psycho - analyst described PK as a woman who detested weakness, especially in women. This was interpreted as a form of self-hatred; problems with expressing feelings were also noted and a severe neurotic disorder diag - nosed. Compulsory outpatient psychotherapy was recommended. PK set fire to a shopping centre causing serious damage. A new forensic psychiatric report was commissioned, which described PK as a woman who tried to hide her femininity, had poor self-esteem and tried to gain recognition by becoming a notorious criminal. Lack of impulse control, quickly changing mood states and problem-solving difficulties were also identified. A diagnosis of dissocial personality disorder (ICD-10) was made. PK was convicted and sentenced to four years’ imprisonment sus - pended in favour of indefinite detention. 1 She was first received into a low security prison but had to be transferred to higher security, as she attacked Frei et al.

There, she received analytic therapy. 1994 On appeal, PK was reassessed. Progress was acknowledged, but further inpatient treatment was recommended, although in open conditions. Her sentence was reduced and the indefinite detention order overturned. 1995 PK was released from prison; it later became clear that she had started fire setting and committing burglaries again shortly after release. 1996 As PK successfully concealed her antisocial activities, she was released from the requirement to participate in outpatient treatment. However, she continued therapy on a voluntary basis and lived in a hostel for released prisoners. 1997 PK killed a 61-year-old woman in a public park, inflicting some 30 stab wounds and then hitting her with a large stone. PK was not initially a suspect for this murder. 1998 PK attacked two police officers with a brick. Three weeks later, she went to a bookshop from which she had been ejected a year before for browsing with no intention to buy, ripped open the throat of the elderly female shop-owner, and took money. Against expectation, the victim survived; again PK was not a suspect. PK confessed to her therapist urges to commit arson, and was remanded to prison. She was transferred to the secure forensic psychiatric hospital after threats to self-harm. Progress on the ward During the first interview PK disclosed nightmares of stabbing a woman in a park, which was dismissed as ‘pseudologia phantastica’. PK was allocated a single room because of her stated hatred of women. She decorated her room in a child - like way with pet posters and a teddy-bear. Apart from outbursts of despair and weeping she did not initially present any management problems. These first arose when PK had to attend outside appointments accompanied by officers in uniform. She stated that she detested uniformed men and attacked them. She started an affair with a male patient detained for attempted rape, requested a pregnancy test and despaired when he was returned to prison. PK repeatedly recalled wandering around the city in order ‘to terrorize women’ and suspicion arose as to her involvement in the unresolved murder in 1991.

Confronted with this, PK attacked a nurse, trying to strangle her. She had to be restrained and was sent back to prison. There she confessed both completed kill - ings and the attempt on the shopkeeper’s life.

Mental state PK was small, slender, clean, tidy and boyish. She generally avoided eye contact and was initially rather suspicious. Although her speech was normal in rate, Female serial killing Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006) DOI: 10.1002/cbm R1 173 rhythm, volume and spontaneity, her mood could change rapidly from dysphoric- irritated to relaxed-cool. When dysphoric, she showed extreme motor agitation and was very tense. PK sometimes expressed suicidal ideation, but said she was too cowardly to do it. PK expressed hatred for all human beings, especially women, and expressed disgust for all forms of sexual behaviour. She presented with a rigid moral code but her aim in life was to become a notorious criminal.

At times, PK expressed urges to attack, which she tried to resist. She had no classically psychotic features. In terms of counter-transference, PK would raise empathy, fascination and interest.

Attitude towards offences PK referred to her acts of arson as ‘some strange kind of hobby’. She stated that she wanted to ‘cause as much damage as possible’ and ‘spread terror’. In relation to the killings, she said she saw women as easy victims, and felt ‘excited’, ‘like a savage in face of his hunting prey’ when she saw them. Concerning the attempted murder, she expressed surprise and disappointment that the victim had survived, since she, PK, was ‘a perfectionist’.

Physical examinations All physical examinations, including serological, haematological and chemical blood tests, EEG, MRI and a gynaecological examination were within normal range.

Psychological assessment PK’s IQ was within the average range according to the Standard Progressive Matrices (Raven et al., 1987) and Reduced Wechsler Intelligence (Dahl, 1972) tests with higher scores on verbal than on performance subscales. Performance on the Visual Retention (Benton, 1981) and d2 Test (Brickenkamp, 1978) were within normal range indicating no difficulties in concentration, visual percep - tion, visual memory, and visuo-constructive abilities. Personality inventories revealed high rates of aggression, irritability, narcissism, impulsivity and border - line personality traits.

Forensic opinion The forensic psychiatric opinions found that PK fulfilled ICD-10 criteria for a mixed personality disorder, but not mental illness. She was considered to fulfil the criteria for diminished responsibility, but not insanity. Due to her dangerous - ness and limited treatability, unlimited detention in prison for the protection of others was recommended. Frei et al.

Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006)DOI: 10.1002/cbm R1 174 Discussion The literature on female serial killing suggests that – in contrast to men – women serial killers tend to know their victims, often partners or helpless individuals in care; their methods of killing are usually covert; motives may be of a material nature; and sadistic gratification is rare. Commonly offences are committed with a man or men. The patient described here, PK, did not fit this ‘type’. She committed her crimes against strangers, using violent methods in an area geographically distant from her home. As a single-acting female perpetrator she might be compared to the case of Aileen Wuornos in the USA, who killed seven men by shooting while working as a prostitute. Aileen Wuornos was a lesbian who had been severely neglected as a child and had been repeatedly raped (Hickey, 1997). Using Holmes and Holmes’s (1998) classification (see Table 1), Aileen Wuornos and PK both fit best in the category of the ‘hedonistic’ or ‘power seeker’ type of female serial killer. From a psychodynamic perspective, the concept of the primitive defence mechanism of malignant narcissism (Kernberg, 1992) has been proposed in the conceptualization of serial killing. Individuals with a narcissistic personality structure show grandiosity, a psychological need for power and may display unre - strained aggression, antisocial behaviour and ego-syntonic sadism. Abuse and severe neglect have been found to be associated with this personality (Haller, 1999; Turco, 2001). We did not, however, find any indicators of serious abuse in PK, so malignant narcissism may fail to provide a convincing explanation for her murderous behaviour. A neurobiological approach to aggressive behaviour, antisocial personality disorder and psychopathy has been advanced (for a review see Brower and Price, 2001). More recently, a neuropsychiatric developmental perspective has been presented in the discussion of serial killing (e.g. Silva et al., 2002; Silva et al., 2004). Specifically, these authors introduced autistic spectrum disorder (ASD) psychopathology into the debate. Autistic spectrum disorders (ASD) – which are more common in males than in females (Berney, 2004) – are characterized by a triad of symptoms: impairment of social interactions, communication difficulties and restricted, repetitive patterns of behaviour. They have an onset in early childhood but persist into adolescence and adulthood when they often become more apparent and disabling as social skills become more important (Berney, 2004). A number of case reports of patients with ASD, most commonly Asperger’s syndrome, offer descriptions of sexual and physical violence in this group (Siponemaa et al., 2001). It has been suggested that a lack of understanding of another person’s thoughts and feelings (Theory of Mind and empathy) underlies the aggression of individuals with ASD (Murrie et al., 2002). PK displayed some symptoms consistent with ASD, specifically difficulties in social relationships, lack of interest in such contacts and impaired communica - Female serial killing Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006) DOI: 10.1002/cbm R1 175 tion (avoiding eye contact). She pursued some strange interests and preoccupa - tions and an odd, rigid sense of morality. Behavioural symptoms evident in PK such as fire setting, temper tantrums and stalking have also been observed in individuals with ASD (Murrie et al., 2002). A definite diagnosis of a pervasive developmental disorder in PK is complicated by the rather poor quality of infor - mation regarding her early development. Antisocial and schizoid personality disorders are among the differential diagnoses of Asperger’s syndrome (Berney, 2004); schizoid personality disorder and Asperger’s syndrome are closely related (Wolff, 2000). The distinction between these personality disorders and ASD is particularly challenging in cases of relatively mild symptoms of ASD and becomes more blurred as aetiological models for both disorders have moved closer together. We suggest that PK’s psychopathology is best conceptualized in a dimensional way with dissocial, borderline, schizoid and narcissistic personality features as well as traits of an autistic spectrum disorder. The recognition of a potential developmental perspective in this patient’s presentation will be important for her further treatment and management and is crucial to accurate assessment of future risk.

Note 1. In the country of PK’s residency indefinite detention can be ordered after or instead of a determinate prison sentence for the protection of the public. People subject to such order can be detained in prison or hospital.

References Benton AL (1981) Der Benton-Test. 5. Auflage. Bern: Hans Huber. Berney T (2004) Asperger syndrome from childhood into adulthood. Advances in Psychiatric Treatment 10: 341–351. Brickenamp R (1981) Test d2. Aufmerksamkeits–Belastungstest. 7. Auflage. Göttingen: Hogrefe. Brower MC, Price BH (2001) Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review. Journal of Neurology, Neurosurgery and Psychiatry 71: 720–726. Burgess A, Hartman C, Ressler R, Douglas J, McCormack A (1986) The presumptive role of fantasy in serial sexual homicide. Journal of Interpersonal Violence 1: 251–272. d’Orban PT (1990) Female homicide. Irish Journal of Psychological Medicine 7: 64–70. Dahl G (1972) WIP – Reduzierter Wechsler-Intelligeztest. Hain: Meisenheim. Haller R (1999) Maligner Narzissmus und Sexualmord, dargestellt am Beispiel von Jack Unterweger. Archiv für Kriminologie 1–2: 1–11. Hickey EW (1986) The female serial murderer 1800–1986. Journal of Police and Criminal Psychology 2: 72–81. Hickey EW (1997) Serial Murderers and their Victims , 2nd edn. Belmond, CA: Wadsworth. Holmes R, Holmes S (1998) Serial Murder , 2nd edn. Thousand Oaks, CA: Sage Publications. Frei et al.

Copyright © 2006 John Wiley & Sons, Ltd 16: 167–176 (2006)DOI: 10.1002/cbm R1 176 Johnson BR, Becker JV (1997) Natural born killers? The development of the sexually sadistic killer. Journal of the American Academy of Psychiatry and the Law 25: 335–348. Kelleher MD, Kelleher CL (1998) Murder Most Rare: The Female Serial Killer. Westport, CT: Praeger. Kellermann AL, Mercy JA (1992) Men, women and murder: gender-specific differences in rate of fatal violence and victimisation. Journal of Trauma 33: 1–5. Kernberg OF (1992) Severe Personality Disorders. New Haven, CT: Yale University Press. Mercy JA, Saltzmann LE (1989) Fatal violence among spouses in the United States 1976–1985. American Journal of Public Health 79: 595–599. Mitchell EW (1997) The aetiology of serial murder: towards an integrated model. Dissertation. Murrie DC, Waren JI, Kristiansson M, Dietz PE (2002) Asperger’s syndrome in forensic settings. International Journal of Forensic Mental Health 1: 59–70. Papazian LM (2001) Literature review on the personalities and patterns of serial killers. Dissertation. Raven JC, Court J, Raven J (1987) Raven-Matrizen–Test. 2. Auflage. Weinheim: Beltz-Test Gesellschaft. Scott J (1996) Serial homicide. British Medical Journal 312: 2–3. Schurman-Kauflin D (1999) Profiles of the female multiple murderer. Dissertation.

Siponemaa L, Kristiansson M, Jonson C, Nydén A, Gillber C (2001) Juvenile and young adult disordered offenders: the role of child neuropsychiatric disorders. Journal of the American Academy of Psychiatry and the Law 29: 420–426. Silva JA, Ferrari MM, Leong GB (2002) The case of Jeffrey Dahmer: sexual serial homicide from a neuropsychiatric developmental perspective. Journal of Forensic Sciences 47: 1347– 1359. Silva JA, Leong GB, Ferrari MM (2004) A neuropsychiatric developmental model of serial homi - cidal behaviour. Behavioral Sciences and the Law 22: 787–799. Trube-Becker E (1982) Die Frau als Täter und Opfer von Gewaltdelikten aus rechtsmedi- zinischer Sicht. In: Nass G Gerechtigkeit für Frauen. Beiträge zur soziologischen, psychologischen und kriminologischen Problematik , 23–50. Wiesbaden: Akademische Verlagsgesellschaften. Turco R (2001) Child serial murder – psychodynamics: closely watched shadows. Journal of the American Academy of Psychoanalysis 29: 331–338. Wilson W, Hilton T (1998) Modus operandi of female serial killers. Psychological Reports 82: 495–498. Wolff S (2000) Schizoid personality in childhood and Asperger syndrome. In: Klin A, Volkmar FR, Sparrow SS (eds). Asperger Syndrome. New York: Guilford Press pp. 278–305. World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems , 10th revision. Geneva: World Health Organisation. Zagar R, Arbit J, Hughes JR, Busell RE, Busch K (1989) Developmental and disruptive behavior disorders among delinquents. Journal of the American Academy of Child and Adolescent Psychiatry 28: 437–440. Address correspondence to: Birgit Völlm, Clinical Lecturer and Specialist Registrar in Forensic Psychiatry, University of Manchester, Neuroscience and Psychiatry Unit, Stopford Building, Oxford Road, Manchester M13 9PT, UK.

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