Mental disorder is a cause of crime: what is "mental" in "mental disorder"?

Numerous definitions of “mental” have been attempted over the years, but consensus on its definition remains to be established (just as its two sibling words, "psyche" and "spirit", but let us focus on mental here). This is noteworthy, as it is a core definition not only in sciences on the mind and its disorders, but also in legislation and cultural references. "Mental disorder" is a key phrase for forensic psychiatry in many legislations, and it is important that we strive to be as clear as possible about how we use and what we mean with the term. After a brief foray into the body-mind problem next week, we will return to "disorder" in a fortnight. But let's focus on the "mental" part of "mental disorder" for now. 

In forensic psychiatry, as clincians, we will probably have to do with some examples of what mental can, and cannot, be. The task of further definitions belongs rather to philosophers, or the field of jurisprudence, or even to philology. It is interesting to try to grasp how the Greek and Latin words for mind, soul and spirit have evolved in the European languages, and often have come to refer to differnt or overlapping concepts in different contexts. 

Psychiatry has also used several words, such as mind, psyche or senses, without clear definitions and without too much worries over distinctions. Historically, it has tended towards mind and mental in the Anglo-Saxon culture, and towards psyche, soul or senses in continental European or Scandianvian cultures (but these are merely tendencies, just as psychiatrist means "doctor of the soul" in English, references to "mental" are common in French, German or Swedish).  

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association (APA) described mental as: a) inner experiences, relating to mood, thought content, or sensory experiences, b) behavioural patterns, and c) cognitive functions such as learning, social understanding and reality assessment.

As these descriptions refer to different ways of conceiving the human, let us refer to them as aspects of the mental. 

The first aspect, inner (subjective) experiences, denotes the inner life that a subject can be aware of. Mental representations are not limited to sequences of language but may be “iconic” or non-symbolic, merging sensory input with memories and emotions.

Subjective experiences are made the object of science by methods that are basically hermeneutic in a wide sense and dependent on the clinical encounter. The requirement that scientific knowledge should be possible to generalize to persons other than those under direct observation is as important for assessments of inner experiences as for behaviour observations or tests of abilities.

Cognitive processes represent knowledge of the world and the self and are thus intrinsically linked to learning and structured by language. Learning, and the ability to learn, are more accessible for quantification than inner experiences, and may, in part, be evaluated by tests.

The behavioural manifestations of the mental were once proclaimed by behaviourist philosophers and psychologists to be the only aspect accessible for scientific exploration. Behaviours do indeed lend themselves to quantification by various forms of assessments based on their observability (self-rate, collateral, or clinician-rated), but it may be misleading to refer to "mental" aspects if behavioural manifestations are all that have been studied. 

Generally, these descriptions of mental aspects complement each other, and together form an ideal for clinical work. In the forensic context, however, test-retest reliability, transparency, and objectivity become more important than comprehensiveness. Behaviour assessments and cognitive tests may therefore be more acceptable and useful than hermeneutic assessments of inner experiences.

In forensic psychiatry, the concept of "mental" may thus be limited to include only such law-bound patterns of behaviours and faculties that are possible to describe by replicable metods.

This blog post is partly excerpted from the paper "Mental disorder is a cause of crime" co-authored with Susanna Radovic, Christer Svennerlind, Pontus Höglund and Filip Radovic in 2009. 

"Hypermodern times" by Gilles Lipovetsky and psychiatry

In his 2005 book Hypermodern Times, the French philosopher Gilles Lipovetsky refers to the new millennium as “hypermodernity,” that is, something as paradoxical as a “modernist renaissance” characterized by hyperconsumerism, new individualism, narcissism, and a desperate need for control that remains impossible to satisfy in the absence of a belief system.

Lipovetsky puts the new era in the context of modernism and postmodernism, and elegantly describes its many paradoxes. The hypermodern times actually began when the description of postmodernism became common knowledge in the last decades of the 20th century. The predominant emotional chord is described like this:

“The ambience of this civilization of ephemerality has changed the prevailing emotional tone. A sense of insecurity has invaded all minds; health has imposed itself as a mass obsession; terrorism, catastrophes and epidemics are regularly front-page news. /…/ The only real question now is that of protection, security and defense of social benefits, of urgent humanitarian aid and safeguarding the planet.” (p 39)

And about future: “The less one has a teleological vision of the future, the more that future lends itself to being manufactured in a hyperrealist way: science and technology in combination aspire to explore the infinitely great and the infinitely small, to reshape life, to manufacture mutants, to offer a semblance of immortality, to resurrect vanished species, to programme the genetic future.” (p 43)

Psychiatry is, and always has been, medicine's—and perhaps the modern era's—most daring enterprise. Here, man uses natural science to try to explain that thoughts, feelings—even consciousness—have material causes that are subject to the laws of nature and, therefore, are possible to manipulate and predict. Even the name is edgy: the Greek word “psyche” (which few psychologists or psychiatrists can define off the cuff) is the New Testament's word for life, the soul, that which previously was seen as the immortal, God-like, free essence of being human, which, through psychiatry, becomes a part of physiology and pathology.

Mental suffering has been referred to widely divergent conceptions of causes, such as sexual experiences in infancy, capitalist alienation from work, and the “schizococcus,” but from Freud's psychoanalysis to Marxist-influenced social psychiatry, to neuropsychiatry, the same modernist insistence that psychological phenomena can be traced back to sufficient causes has characterized the different schools of thought.

In the hypermodern culture, psychiatric knowledge and tools are suddenly indispensable for people who struggle to use their minds just as their bodies. The spell of the 1970ies anti-psychiatry is broken. As the body has taken on new iconic meaning as a provider of status and bliss, the same perspective is taken on our inner selves, with identity-shaping schemes to create the “dream-me”. Anxiety is controlled with the help of computer programs, visualization techniques, meditation, and other forms of “training.” We even map our genetic predispositions using saliva DNA kits purchased online, and use inventories and websites to match our procreation, love, relationship, friendship, and existential ideals to other people's.

Young people are increasingly seeking out psychopharmacological treatments, not only for impairing conditions but also as “enhancers” of everything from attention span to love or moral judgment. The lust for self-experimentation is striking. Forty years ago, treatment with psychopharmacological agents was widely considered nightmarish. Now, it is clearly mainstream.

With structural and functional imaging methods, epidemiological and molecular genetics, national databases, and broad psychopharmacology, does psychiatry finally have the technology to realize the 1930's modernist ideals of “healthier, clearer, cooler?”

Yet the need for security and predictability is ever-increasing. Instrument-based risk assessments are increasingly used to certify people in order to point out individuals who present some sort of risk. New hospitals use cutting-edge technologies to supervise patients. Do we see the beginning of a new culture wherein neuroscience truly can influence mankind's big questions of peace, happiness, financial security, and global health?

Or will there be a huge disappointment in hypermodernist solutions on the scale of that in the late 1960-early 1970ies? After all, there is very little evidence that psychiatry is improving either general mental health, well-being or the outcome for patients. On the contrary, mental health is getting steadily worse in the hypermodern culture, treatment results have not improved in any general sense and psychiatry itself is getting more repressive, with more involuntary care, forced pharmacotherapies and long-term monitoring. Is this an early sign that hypermodernism is not really all there is to our future?

In 2014, the confidence in the progress of psychiatry seems to have started to dwindle. Funding from the pharmacoceutical industry is drying up, and molecular genetic studies implicate extremes of normal variation rather than identifiable mutations in a large majority of research subjects with common conditions such as depression or even autism spectrum disorders. If mental health problems arise along a spectrum ranging from the normal variation into out-lying pathologies without clear demarcations between disorder-health or between different diagonses, easy technical solutions will be difficult to deliver. 

(Partly excerpted from this paper, available in full text, where changes in psychiatry from modernism to postmodern and hypermodern times are described)

Postmodernism

This post is the first in a series that will run in the blog at weekly, or something like weekly, intervals, called ”Dilettantischer Dienstag” (dilettantish Tuesday). In it, I will develop ideas, topics and interests that are not in my field of expertise, but rather somewhere in my general reading or geeky special interests. Some may think that this is not limited to Tuesdays, but those will at least be the days when these pieces are posted. And, let me remind you that on Fridays, a more serious series called Forensic Fridays will include texts from my actual field of expertise (even if this is certainly no guarantee of infallibility). 

The first dilettantish post will address a somewhat controversial and not too easy subject: the term “postmodern” or “postmodernism”. I have noted that these are now commonly used to denominate a senseless relativism of knowledge, rooted in sloth and misguided egalitarianism. Maybe this has to do with a current faibelesse for "hypermodernism" that Gilles Lipovetsky has sharply described (more on that later). 

In several papers and speeches over the years, I have, however, used the term "postmodernism" to highlight specific aspects of epistemology or ethics (sometimes to the dismay of anonymous peer-reviewers) and often cited with great appreciation the works by Pat Bracken and Philip Thomas on “Postpsychiatry” or “Postmodern psychiatry” (http://www.bmj.com/content/322/7288/724, also a monograph in the Oxford series on Philosophy and Psychiatry, http://www.amazon.co.uk/Postpsychiatry-Postmodern-International-Perspectives-Philosophy/dp/0198526091). Therefore I will briefly try to remind you about its original and – I believe – still valid use. These texts come from a paper I published in Swedish in 2011 (the excerpts are not at all original of course, but hopefully of some educational value) and may be found here http://celam.gu.se/digitalAssets/1481/1481973_postmodern-psykiatri.pdf . 

In 1979, Jean-Francois Lyotard described his time as the ”postmodern condition”, not as a “movement” or a programmatic –“ism”, but as a condition characterized by skepticism towards “meta-narratives - sometimes ’grand narratives’, /…/ grand, large-scale theories and philosophies of the world, such as the progress of history, the knowability of everything by science, and the possibility of absolute freedom”. 

Postmodernity therefore does not entail nihilism in relation to knowledge or relativism. Instead, awareness of epistemic frames (which questions can be answered by a certain method) leads to more rigorous science. “Grand narratives” form obstacles to understanding what new information really means and lure us into drawing conclusions that are not founded in the scientific data or into extrapolating interpretations to contexts where they are not relevant. They also create artifactual conflicts between different perspectives and make it more difficult to see that knowledge is generated in “cuts” through reality, dependent on the perspective from which a phenomenon is examined, and that different contributions, as long as they are, each and every one, rigorous and epistemologically consequent, can be used as complementary rather than excluding.

I will continue to use these terms and hope to elicit some further interest for the issues at stake. 

The original Swedish quotes from the paper:

År 1979 beskrev Jean-Francois Lyotard sin samtid som det ”postmoderna tillståndet”, alltså inte som en ”rörelse” eller ”-ism” med ett program, utan som ett tillstånd präglat av skepsis mot ”meta-narratives – sometimes ’grand narratives’, /…/ grand, large-scale theories and philosophies of the world, such as the progress of history, the knowability of everything by science, and the possibility of absolute freedom”.

Postmodernitet behöver inte innebära kunskapsnihilism eller relativism. Medvetenhet om kunskapsteoretiska ramar (”vilka frågor kan denna metod besvara?”) leder istället till en mer rigorös tolkning av vetenskap. ”Stora berättelser” hindrar oss från att förstå vad ny information egentligen betyder och lockar oss att dra slutsatser utan stöd i det vetenskapliga underlaget eller att extrapolera tolkningar till sammanhang där de inte är relevanta. De skapar också artefaktiska motsättningar mellan olika perspektiv, och gör det svårare att se att kunskap genereras i olika ”snitt” genom verkligheten beroende på ur vilket perspektiv fenomen undersöks, och att olika bidrag, så länge vart och ett är rigoröst och kunskapsteoretiskt konsekvent, därför är komplementära istället för exkluderande.

My thoughts on forensic psychiatry (from March 2014)

My research largely addresses the importance of neuropsychiatric problems on our ability to take responsibility for how we act, how we relate to others and to something or someone to give our lives meaning (our ‘character’). This text is an excerpt from my researcher's presentation at the CELAM website (http://celam.gu.se/people/henrik-anckarsater/).

Today, we know that risk factors and protective factors can be found in our genes, in brain development and in the biochemical/physiological processes that interact with our mental processes. Research has established probabilities resulting from many different factors, rather than causation in the classic (mechanistic) sense. Life is thus unfair in the sense that we must contend with different predispositions--and of course relate to different environments. Some of us find it easier to mature as individuals than others, as well as refraining from violence.

In addition, habits and learned patterns further restrict our freedom, and our knowledge about the consequences of our actions is incomplete. Therefore it is important that we as health care professionals meet people without preconceived notions about what they can and cannot be held accountable for. The role of the doctor is to restore health and thus the conditions for accountability.

However, this does not mean that science has excluded that thoughts or intentions may affect the body and physical actions in the world. Patients who believe they are receiving treatment for Parkinson’s disease show an increase in dopamine release in the brain, even if no treatment is given. The world is changed by ideas. We all know that willpower is essential to cope with challenges, that thoughts can provide courage when faced with fear, that love must be given freely and that we are expected to be held responsible for the way we act, vote and conduct businesses.

The interplay of brain, senses and soul that creates a person remains a mystery that science has been unable to explain. Yet we have reason to believe that these are aspects of the same phenomenon (‘neutral monism’).

But this image has not been, and is not, consistent with the current view in forensic psychiatry. Instead, the specialty builds on the assumption that humans are materially motivated according to the laws of nature. Therefore, forensic psychiatry has either advocated for criminal law legislation devoid of the metaphysical (of concepts such as competence, responsibility and punishment as a way to atone for the guilt of a crime), with protection of society and treatment as the sole objectives, or for a compatibilist model in which the person is held accountable, even if it is believed that (s)he was unable to have acted otherwise.

Sweden went further in this direction than any other country with the 1965 introduction of the Criminal Code, which replaced the old Penal Code with a series of ‘sanctions’ to various types of ‘care’ (prison, forensic psychiatric care, probation, juvenile care, etc.). Today everyone seems to agree that this system has not functioned as intended, and that it should be replaced.

I believe that we would be well advised, prior to the upcoming revision of the Criminal Code, to exercise restraint in ‘translating’ psychiatric knowledge into law, since these two fields have different points of departure: one wants to eliminate the causes of ill health, and the other wants to hold people accountable for bad actions they intentionally commit.

What we as doctors can comment on with certainty in courts of law is the lack of alertness, orientation and clarity (disturbances in the thought processes). Such impairments may be due to mental or physical illness and may have ‘destroyed’ the ability to act responsibly. In such cases (for example, in severe confusion or dementia), just about anyone can understand what has happened and it is difficult to see how any intent has arisen in a legal sense.

However, when doctors assess thought content, assessments become much more uncertain (as we have seen in court cases garnering media attention, such as that of the Norweigian terrorist Anders Behring Breivik).

If future Swedish law assumes that responsibility is the norm and limits the opportunity to obtain special criminal treatment for clear cases in which the ability to act responsibly has been destroyed (as in current international law), more people with mental illnesses will be sent to prison. This scenario would in turn result in higher demands for flexibility in implementation, which must include care and opportunities to finish the sentence in open forms.

The challenge is twofold: to accept the need for a well-functioning rule of law while offering all proper care as needed. A person may be psychologically disturbed, in need of care and accountable for their actions, all at the same time. It is even the norm in the justice system, where most prison inmates require various care interventions. As psychiatrists, our mission is to provide care, develop knowledge and propose changes to make justice more therapeutic (‘therapeutic jurisprudence’), but not to take over responsibility from lawyers or to naively translate our knowledge into their field.

When we conduct research about people, we work in different epistemological frameworks, which have different premises to respond to different questions. For example, brain imaging studies can show the appearance of brain activity while lifting an arm, but cannot answer the question of whether lifting the arm was a good idea.

We must work to rigorously interpret scientific knowledge within these epistemological frameworks. Forensic psychiatry has often extrapolated results from a methodology that answers questions that address an entirely different aspect of human behaviour (‘Charlie didn’t break the window, it was his ADHD that did it’ or ‘if he had a brain tumour, you wouldn’t think he was to blame’ even though most people with ADHD or brain tumours do not commit crimes).

The relationship between mental disorders and physical aggression is not simple to untangle. The majority of all violent crime in society is committed by a small group (1% of the population), almost always men who started to behave violently early in life and continued to do so. They have also had problems with hyperactivity, impulsivity and/or abuse. This group is also overrepresented in every diagnosis group within psychiatry, but the distinction between ‘chicken and egg’ is unclear.

People with psychoses are at greater risk of committing crimes, but this is due to a sub-group of people who also had early behavioural problems and progressed to abuse and crime. Genuine ‘acts of madness’ among previously non-violent individuals are extremely rare and essentially impossible to predict, since they tend to occur either early in the course of disease (when they can be bizarre and directed against strangers) or late, often directed at family members and without specific warning signs.

A central task of forensic psychiatry has been to carry out risk assessments of individuals who may be prone to violent acts. Recent research has shown that such assessments are based entirely on a combination of earlier behaviour with age at onset, substance abuse and gender. It has not been possible to show that any specific psychiatric factors increase accuracy beyond the prediction achieved by the above data. Therefore, I think we as health care personnel must refrain from speculating about long-term risk.

However, our mission is to help people who have or are about to develop patterns of antisocial aggression and to try to prevent violent acts through a here-and-now perspective. The most important step toward this end is to develop methods of breaking the pattern of early violent behaviour in children and adolescents, while helping them to avoid substance abuse and marginalization. To achieve this goal, schools must offer an environment free of violence, where the law is upheld and where it is just as obvious that children are not allowed to hit one another as it is that adults are not allowed to hit them. For those who wish to learn to use violence, options include sports and activities within the societal monopoly on violence. If specially trained school police officers are necessary to secure a good environment for children and to ensure that fighting and threats of violence do not become a ‘winning strategy’, then we must raise this discussion.

In recent years a new and rather unexpected problem has arisen at the juncture between psychiatry and law. The results from various studies suggest that current psychiatric diagnoses may not be supported by scientific reasoning. Consensus between different assessments is much less than we thought. The same risk factors and biomarkers seem to give rise to completely different problem complexes in different people. Almost no patients have a ‘pure’ diagnosis, but many diagnoses are made on a case-by-case basis and regularly change with each new care provider. Medications often affect many different problems and, with few exceptions, are not specific to any particular diagnosis. In 2013 there was even talk in the journal Nature that addressed psychiatric theory, comparing it to a broken airplane in the air requiring ‘in-flight’ repair. I think we must take this very seriously with a humble approach to new scientific findings if we are to maintain credibility in our specialty.

To sum up, I believe that forensic psychiatry should focus on treatment of those individuals who actually want treatment, starting by clearly defining problems instead of using diagnoses: assess patterns of aggressive antisocial behaviour, psychosocial dysfunction and/or suffering, and then without bias work with scientifically identified biological, cognitive, affective, behavioural and social risk and protective factors. It is encouraging that aggressive antisocial behaviour is a clinically meaningful, somewhat stable and recognizable problem complex for which neuroscientific studies and therapeutic research hold promise.

I have written my ideas as of March 2014 in this text as simply and clearly as possible. I have not backed the arguments with references, but should anyone who reads this online wish to discuss any of the points in the text and share any publications that either support or conflict with my ideas, please feel free to contact me by email, and perhaps such correspondence can be developed into a blog post about forensic psychiatry.