By H. Steven Moffic, MD
There has been increasing publicity about the imminent end of the world on December 21, 2012, as possibly posited in the Mayan Calendar. What we do know for sure, is that for all the young children and adults who were killed in Newtown, Connecticut, their world ended a week earlier, on December 14th.
As the play of the same name by Thornton Wilder, Newtown Is Our Town.
The perpetrator must be, in some way, everyman. We must be our brother's keepers. Any field that can contribute to the understanding and prevention of the increasing numbers of attempted and successful mass murders in the United States must work on this for the next weeks, months, and years. Psychiatry is surely one of these.
Diagnosis
Amidst all the initial speculation on the reasons for the tragedy, my wife noticed an e-mail from a psychiatrist that struck us as possibly revealing deeper issues, some perhaps indirectly relevant. The subject was "Autism not a Mental Illness." Autism was one of the initial diagnoses associated with this killer. Beyond such premature diagnostic speculations, the e-mail was reacting to a CNN coverage in which a physician and a reporter discussed that autism may not be an illness, since NIMH was considering autism and other mental conditions as "neurogenerative." Perhaps, the e-mailer suggested, if autism was not considered to be a mental illness, would that be better because then, if the murderer did not have a mental illness, mental illness could not be blamed for the mass murder.
This argument, though cumbersome, leads us to take a step back and take a bit of a detour. First of all, there are no mental illnesses, at least so far as the terminology goes for the DSM and ICD classifications of mental conditions. This is more important than mere semantics. These conditions are called disorders, not illnesses or diseases. The prime definition of disorders, in my Webster’s dictionary, is "confusion."
However "disorder" is defined, it causes mental conditions to appear to be different from medical illnesses. It implies that clinicians other than psychiatrists can be expert in the diagnosis and treatment of those disorders. Indeed, that is one of the issues that I was concerned about in the March 10, 2010 blog, "The DSM Process: More Questions Than Answers." The cautionary statement as to who can make a diagnosis reads: "It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses occupational and rehabilitation therapists and counselors."
So much for the medical expertise of psychiatrists in making a diagnosis. As far as I know, that consideration will not change in the upcoming DSM-5.
This is a scenario that is more likely to lead to an inadequate diagnosis or missed diagnosis. Moreover, diagnosis, though necessary for reimbursement, research, and a general sense of what is wrong, should only be the necessary, but not sufficient, step in understanding an individual. Adequate time and analysis is required. As the bio-psycho-social model implies, we have to look far and wide to try to understand anyone. If indeed the perpetrator of the Newtown tragedy fell on the Autism spectrum, how often does a mass murderer have that diagnosis?
Guns
As so many have commented, the ease of obtaining automatic weapons can indeed contribute to mass destruction. If someone has untreated mental problems, the risk also increases. Adding guns and knowing how to use them, to someone with apparent mental problems, surely increases the odds of something bad happening.
Any positive reinforcement of gun use, outside of controlled situations such as hunting, may cause more unnecessary harm than benefit. Certainly, we have a lot of positive reinforcement and modeling of a gun culture in our Constitution, our seemingly endless war, and violence in the media. The more impersonal ways of relating on the internet may veer us more toward the social deficits and lack of empathy that is characteristic of the Autism spectrum.
Evil
I never used the term evil professionally or personally until I worked in prison part time at the end of my clinical career. For many of the inmates I saw, mental disorders, including substance abuse, seemed to play a significant role in their crimes. Gang involvement, where self-esteem and identity, was enhanced through group process, was another significant factor for many. On a rare occasion, neither a mental disorder, including antisocial personality disorder, nor gang behavior, seemed to be enough of an explanation.1 That is when I began to think more seriously of evil, as did many in the aftermath of this recent tragedy. The Governor of Connecticut claimed that "evil visited this community . . . ." Later he expanded that to mental illness dressed in evil. Perhaps that can be further expanded to mental illness dressed in evil and a holster.
Recommendations
Soon after the tragedy, one of the fathers of a child killed tearfully pleaded for society to learn from what happened in order to prevent future mass murders. Here's what I think psychiatry can contribute:
Autism, Asperger, and most every other mental condition worthy of our prime focus should be called diseases, not disorders
All such diagnoses should be made or certified by a psychiatrist to qualify for medical insurance coverage
Do not make public diagnoses of anyone not personally examined, per our Goldwater Rule
This tragedy, following too many others, should spur further study of where criminal behavior ends and psychiatric disease begins, if indeed there is even such a line
All psychiatrists should spend some clinical time in a correctional institution, either during residency or later for continuing education
Find better ways to educate the public about the early signs of homicidal risk
Advocate for a system of safe reporting of those felt to be at- risk for homicidal behavior
Provide better resources in order to improve early treatment of homicidal ideation
Convene a representative body of those injured by public violence and loved ones of those murdered, to work on a national Task Force to reduce mass murder
Advocate for a special anniversary date or holiday, December 14th, to not only remember the Connecticut tragedy or others like it, but also as a way to monitor how we are doing as a nation and a profession in trying to prevent more such tragedies.
Reference
1. Moffic HS. Better Off in Prison; 2011. Psychiatric Times. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1850954. Accessed December 17, 2012.
