Maryland's new Center for Excellence on Early Intervention for Serious Mental Illness holds out the promise that for some people with mental illness — especially psychosis — early intervention may reduce the chance, already small, that they will become killers. Any reduction in the growing trend toward murder and mass murder in our country would be welcome.
This plan is a refinement of an approach, long practiced though currently under attack, of early intervention and treatment, almost always with psychotropic drugs, of behavior that is diagnosed as "early onset" schizophrenia in children who have psychotic symptoms — usually, paranoia, delusions and hallucinations.
The problem is that our current diagnostic system, based on the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), does not guide the clinician in distinguishing the different reasons why someone of any age may be having psychotic thoughts or behaving psychotically. The DSM-5 considers all mental illnesses to be brain diseases, which is to say that these illnesses are caused by a glitch in brain structure and/or function.
In contrast to the lack of definitive evidence that schizophrenia is a brain disease, there are persuasive psychodynamic explanations for why someone would choose what amounts to a fantasy world over "reality" in the face of anxiety so intense and overwhelming that no one who has not experienced it can imagine such an alternative. The literature on this notion has been pushed aside by the practice and promises of biological psychiatry.
The illnesses of some, though not all, people with psychotic symptoms may be understood by identifying the facts that comprise the stories they tell, and discerning how these facts relate thematically to these symptoms. This amounts to identifying the defenses patients have put in place to "save" themselves from the terror they are feeling, which in turn derives from traumatic life events, and possibly psychobiological deficit. Again, the DSM-5 is no help here. Clinicians have to look elsewhere to learn how to distinguish an often chronic psychotic defensive stance toward the world from a brain disease that produces psychotic symptoms.
Many murders committed by those with psychotic symptoms originate in a distorted notion of reality that leads them to take a life — or many lives — because, to them, in their state of mind, this is the right thing to do. If a mother drives her car into a river with her children beside her because she believes they are possessed by some evil force and need to be destroyed to preserve the integrity of the world, this may be because, in a desperation that is unimaginable to us, she has convinced herself that this is the only solution. The right clinician might be able to persuade her otherwise, providing enough support for her to accept the added anxiety of re-choosing reality over the defensive and "safer" world of psychosis.
Many murders happen because people come to feel they are nobody and see no way to become somebody. To these people, the identity associated with becoming a murderer is preferable to having no identity at all. Others kill because they feel they have been grievously harmed — psychologically killed in fact — and must kill the "killer" in order to get back their own lives. Some young people who are bullied at school follow this course. If a single murder does not satisfy the need for psychic restoration, self-styled victims may kill not only the person who harmed them, but others and then themselves so that everything ends in a blaze of media-covered annihilation.
Those who will staff the Center for Excellence on Early Intervention for Serious Mental Illness have their work cut out for them. I suspect they will be more successful if they try to understand why patients have psychotic symptoms and what these symptoms mean. Some clinicians will cringe at this suggestion because it contrasts so dramatically with current practice and requires a kind of diagnostic skill that few have. To be sure, many psychotic patients will not be candidates for this kind of differential diagnosis.
Imagine being incorrectly diagnosed with a brain disease and treated with neuroleptic or atypical antipsychotic drugs, which are known to mimic the symptoms of schizophrenia, instead of being given the help to confront what is really going on, along with the hope that this illness can be overcome.
Understanding, as far as possible with what is known today, whether those with psychotic symptoms have defensively put themselves in that situation or whether a malfunctioning brain is primarily responsible would probably help clinicians to make the call about whether someone is dangerous. So far, the mental health profession, by its own admission, has not been very successful at doing this.
René J. Muller is the author of is "Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession". His email is firstname.lastname@example.org.