LIMITS OF PSYCHIATRIC DIAGNOSES ARE REVEALED BY MASS SHOOTERS
SEEKING EASY ANSWERS FOR UNTHINKABLE CRIMES
When Christopher Harper-Mercer killed nine people at Umpqua Community College in Oregon on October 1, 2015, it once again plunged America into a debate that has become all too familiar. In response to President Obama's call for stricter gun control, several would-be presidential candidates expressed a newfound interest in mental health issues. The disparate arguments from each side of the political spectrum illustrate how multiple discourses—political, judicial, ethical, sociological, and psychiatric—intersect in the attempt to understand and, ultimately, curb the recent surge in these horrific mass murders. (Editor's note: see Medscape's interview with Nilsson discussing Breivik here)
Unfortunately, the immense complexity of the issue at hand is often ignored in favor of overtly simplistic explanations à la Ann Coulter's now famous dictum, "Guns don't kill people, the mentally ill do,"[1] or Malcolm Gladwell's bold statement that in a pre-Columbine world, would-be killers like Minnesotan teenager John Ladue would have, "played with chemistry sets in their basements and dreamed of being astronauts."[2]
In the face of the terror and suffering inflicted by these attacks, it is unsurprising that causal explanations are in high demand. However, such vulgar statements remaincounterproductive, as they do little to further our understanding of these tragic incidents. No single discipline—including psychiatry—should presume to be able to resolve such intricate issues on its own. While avoiding making any grand claims regarding the societal foundations of these events, there is value for our field in examining them in greater detail. Tragic as they are, they might serve as a prism through which some of our profession's shortcomings become painfully clear.
Inescapably, speculation regarding the sanity of the perpetrator seems to follow in the wake of cases of mass murder yet often remains unresolved. It is still a matter of public debate whether or not Sandy Hook killer Adam Lanza might have suffered from a psychotic rather than a developmental disorder.[3]Likewise, in the recent trial against Aurora movie theater shooter James Eagan Holmes, psychiatrists called by the defense and prosecution failed to reach diagnostic agreement.[4]
However, this is not a strictly American problem. In fact, the most striking example of such professional dissidence may be the case of the Norwegian mass murderer Anders Behring Breivik, who slaughtered 77 people in 2011. In the ensuing trial, two psychiatric evaluations arrived at contradictory results; one diagnosed him with paranoid schizophrenia and the other with a narcissistic personality disorder.
PREVAILING DIAGNOSTIC SYSTEMS OFFER LITTLE CLARITY
These failed attempts to clarify a fundamental clinical question—namely whether or not an individual might be considered psychotic—seem to embody broader disappointment with the contemporary dominance of polythetic operational diagnostic systems.[5,6] Not only has the so-called operational revolution failed to translate into advances in etiologic knowledge or the development of mechanistically novel psychotropic drugs, it has also impoverished psychopathologic knowledge as diagnostic manuals have come to be regarded as the ultimate authority on these matters.[7]
Aside from the nearly insurmountable problem of differential diagnosis, the widespread ignorance of descriptive psychopathology has conditioned an epidemic spread of certain psychiatric disorders (attention-deficit/hyperactivity disorder, borderline personality disorder, autism spectrum disorders) and high levels of psychiatric comorbidity defying conceptual understanding.
From the viewpoint of phenomenological psychopathology, this malaise is rooted in an epistemological fallacy regarding the very nature of the object of inquiry. A psychiatric sign, symptom, or biographic fact is not a simple entity. It is not a floating part or thing-like object readily lending itself to a diagnostic algorithm of "symptom-counting."[8] Rather, it is expressive of the totality from which it derives. It reflects an undividable structure of subjectivity, which by virtue of its very ontology must be considered in its entirety. The gestaltic salience of mental disorders is not accessible merely through the brief, lay-language descriptions that, independent of contextual relations, make up the diagnostic manuals.
Accordingly, the problem of differential diagnosis cannot be alleviated by a manual consisting of a multitude of computer-ready binary decision trees, each one starting from a different psychiatric complaint.[9] For one to be able to grasp and make sense of the prototype that manifests itself in a patient, a certain familiarity with the literature as well as clinical training in psychopathology proper is needed. On the other hand, if the clinician is robbed of any sense of gestalt, they are doomed to aimlessly traverse the diagnostic manuals checking off apparently meaningless and unconnected signs and symptoms until transgressing some arbitrary threshold ("At least 4 out of 7 of the following..."), thus reaching a diagnostic conclusion.[10]
This does not confer on the diagnostic process the objectivity sought by the proponents of the polythetic operational approach. Instead, it paves the way for misunderstandings and divergences of opinion and invites idiosyncratic psychological interpretations. This was illustrated in the Breivik case by the discussion of whether his blunted affect should be conceptualized as belonging to the negative domain of a schizophrenic gestalt or as a lack of empathy owing to a narcissistic personality disorder.[11] Such disagreement testifies to the lack of a common prototypically organized conceptual grid, which is wholly essential to organizing the clinician's cognitive field. It discloses a fundamental problem for psychiatry as a scientific—as well as a clinical—enterprise, which cannot be remedied by intensified research in neural circuitry or other subpersonal processes but only by a renewed interest in subjectivity and psychopathology.
REFERENCES:
1 Coulter A. Guns don't kill people, the mentally ill do. AnnCoulter.com. January 16, 2013.http://www.anncoulter.com/columns/2013-01-16.html Accessed November 17, 2015.
2 Gladwell M. Thresholds of violence: how school shootings catch on. The New Yorker. October 19, 2015.http://www.newyorker.com/magazine/2015/10/19/thresholds-of-violence Accessed November 17, 2015.
3 Turndorf J. Was Adam Lanza an undiagnosed schizophrenic? And could a proper diagnosis have averted the Newtown massacre? Psychology Today. December 20, 2012. https://www.psychologytoday.com/blog/we-can-work-it-out/201212/was-adam-lanza-undiagnosed-schizophrenic Accessed November 17, 2015.
4 Healy J. Defense tries to put focus on sanity of Aurora gunman. The New York Times. June 25, 2015.http://www.nytimes.com/2015/06/26/us/defense-tries-sanity-focus-to-spare-life-of-aurora-gunman-james-holmes.html Accessed November 17, 2015.
5 Frances AJ, Widiger T. Psychiatric diagnoses: lessons from the DSM-IV past and cautions for the DSM-5 future. Annu Rev Clin Psychol. 2012;8:109-130.
6 Hyman SE. The diagnosis of mental disorders: the problem of reification. Annu Rev Clin Psychol. 2010;6:155-179.
7 Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull. 2007;33:102-112.
8 Nordgaard J, Revsbech R, Sæbye D, Parnas J. Assessing the diagnostic validity of a structured psychiatric interview in a first-admission hospital sample. World Psychiatry. 2012;11:181-185.
9 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
10 Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci. 2013;263:353-364.