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I started a comment and then remembered you might be one of the people with an actual medical background so I won't perseverate and will ignore some of the misunderstandings of people below.
What's your read on the actual dx? I've been trying my best to avoid the details but the case is now everywhere so might as well try and dig in.
I've also spotted an interesting culture war element, even in medicine (and even among my friends who work in mental health) nearly all of the women don't think she did it (they blame the husband). Most of the men? Think she did it (and with most of those also thinking it wasn't psychosis).
The only exception I've run into was a forensic psychologist.
Perhaps something to chew on.
Comment as you wish! I welcome more discussion even if you think it's redundant. I have education in the issues at hand, though I do not currently work in a diagnostic capacity with psychotic populations. I'd describe more, but I am overly protective of my online footprint and anonymity is why I enjoy participating here.
I haven't read about Clancy extensively, so my comments are tentative and open to correction. Generally speaking, psychotic diagnoses are a shitshow. Presentations vary wildly within the same diagnosis and treatment is a blunt instrument, to put it nicely. The defense claims she experienced some form of bipolar disorder with accompanying post-partum depression. From what I have read, her presentation aligns more with depression with psychotic features, but again, these categories are extremely fuzzy.
Notes taken from her psychiatrist indicate she was experiencing what are commonly called "command hallucinations," or voices that tell you to do things. It seems trivial to us mentally sound folks to resist voices - just say no - but it's not merely a voice. These hallucinations are often experienced like a form of possession, where the voice is accompanied by a loss of control or feeling of being "overridden." I once worked with a man who attempted to strangle me while crying and saying, "I'm so sorry, I don't want to do this." I believe him. He warned me when he was about to lunge so I could avoid it. I knew him well and in his right state of mind, he was a kind and gentle person. During his worst moments, he believed he was possessed by a pagan god. There was nothing we could do to talk him out of it, the only thing that worked were very strong doses of rescue medication (usually benzodiazepines). It is entirely possible that Clancy had similar experiences. It's hard to say. Much of the commentary around her mental health has focused on the depression, suicidality, and sleep disturbances that she experienced, rather than the psychosis. I am surprised the defense has taken this approach.
The other point I'd like to make is that the day-to-day experience of psychosis varies incredibly. I've worked with patients who have had fantastic weeks and consistent upward progress. These good periods can create a false sense of security and normalcy and often result in medication adherence wavering. Naturally, the progress comes to a swift halt (or even regression) in these cases. Even worse, sometimes downturns occur for no apparent reason despite consistent treatment. Here, there is little that can be done other than providing rescue medication, hoping the episode passes, and tweaking the prescription. Even within a single day, presentations can change dramatically. As such, the claim that she could wake up in the morning, take her kids to school, and come home to kill them does seem psycho-medically plausible.
Ultimately, it's hard to diagnose her remotely or evaluate the validity of the expert claims. I am very interested in her presentation these days. She appears to be able to sit in the courtroom with minimal difficulty and is evidently not experiencing these symptoms anymore. Perhaps she's just better at concealing them. I wonder what changed - was it time, or a new treatment?
I've written this and am only now seeing you are a physician. Apologies if some of these observations are elementary to you.
I'm quite interested in the differential, even if the information to really figure it out isn't available (and it wouldn't be appropriate anyway).
The impression I got is that she didn't endorse any CAH before or after the killings until meeting with someone hired by her defense. If this is true....yikes.
While patients lie about and minimize AH all the time it's usually noticeable enough, especially in someone getting enhanced scrutiny (for instance after murdering their children).
I'm therefore not sure I buy that she has some form of postpartum psychosis or unmasked BP w/PF, especially given the blatant doctor shopping, help seeking/unseeking behavior, and odd regimens (which can of course stem from poor clinical care but usually involves some element of questionable patient decision making).
If you toss out primary psychotic pathology it rapidly gets really interesting (and this dovetails into your original post). The observed behaviors are demonstrably abhorrent. Do you need to automatically catch a diagnosis as a result?
DSM personality pathology requires persistence and pervasiveness, I haven't heard any evidence to establish that. Is this instead Cluster-B adjacent coping mechanisms in the setting of some other process such as anxiety, depression, or abusive behavior from the accused of being personality disordered himself husband?
I don't think laymen should really be weighing in on criminality and legal proceedings for psychosis because that gets thorny pretty quickly (aka what is Anosognosia anyway?), but I think it's pretty mainstream and reasonable to treat DSM personality pathology (especially BPD and ASPD) as criminality instead of insanity. Likewise terrible stuff that doesn't quite fit into a diagnostic box.
Although if psychosis was present - it's easy to underestimate the danger in first episode psychosis, without proper practice managing symptoms things can go off the rails very fast.
Uh-oh. In my experience CAH tend to be quite persistent and well-documented, since they are public enemy no. 1 when it comes to patient safety.
I think this is the only scenario that I could really accept - if the killings happened in her first episode of psychosis, prior to treatment. It's going to come down to how thorough her psychiatrists were in documenting the progression and severity of her symptoms, so they can generate a rough timeline of her illness. I think we will probably never know these details and can only hope the court does its due diligence.
My understanding is that she was consistently appropriately assessed for psychotic symptoms through a longitudinal series of interactions with multiple providers including during an inpatient stay. None endorsed and none observed until she met with a defense hired witness (and this was all presented in court).
Now the above could certainly have been misrepresented to me, but I don't think there is really any consistent evidence of psychosis.
That goes a long way towards making criminal liability appropriate.
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