Friday, December 26, 2014

Mental disorder is a cause of crime: "crime" vs. psychiatric phenotypes

The term “crime” is in no less need of a precise definition than “mental”, “disorder”, or “cause”. Leaving aside the legal definition, let us consider how crimes, generally in the form of violent, sexual or aggressive behaviours against others, are approached from the perspective of being caused by mental disorders. 

The focus on mental disorder also directs the searchlight of forensic psychiatry towards individual criminal acts or towards patterns of criminal behaviors occurring in individuals rather than to crime as a societal or group phenomenon. For a number of questions, this is too narrow a perspective.

A crime takes place in a situation, between people, and the vast majority of crimes are clearly influenced by the situations in which they arise. Only rarely is a crime planned and determined by a single mind. A major shortcoming of the psychiatric approach is the emphasis on the individual and the relative down-tuning of the role of the interaction between people, including co-perpetrators and victims. 

The capacity to empathize and act compassionately shows not only a constitutional inter-individual variation but also an intra-individual variation in partially state-dependent actual functioning (cf. Constantino & Todd, 2003; Gabbard, 2004). Each and every one of us may stop forming meta-representations of the other’s mind, the ordinary household quarrel being just as good an example as more dramatic scenes of conflict. 

A person who commits a heinous crime on his own is more likely to differ from the normal variation on at least some mental features than someone taking part in a similar crime as part of a group of offenders. Even small groups may release dynamics that deprive their members of inhibitory forces. A mathematical hypothesis to predict an individual’s actual capacity for empathy (E) would assume that his or her natural capacity for empathy (e) should be divided by the square root of the number of people (n) involved and interacting in the actual act.

Another situational factor that plays a major role in the background to many violent crimes is the influence of drugs. These effects are not easily defined in relation to other mental factors or to situations. Alcohol, for example, may trigger aggression and reduce inhibitory faculties but can also diminish reactivity and reduce anxiety, thus acting as a susceptibility factor or as a protective factor depending on the situation, the degree of influence, and the subject’s other psychological and psychiatric problems. When faced with the task of explaining the background to a particular criminal act, aspects of reduced or changed mental abilities have to be considered in the context of situational, social factors, each of which may constitute an INUS condition.

Perhaps due to this empirical dilemma, psychiatric research has instead attempted a shortcut to explain crimes by diagnosing patterns of crimes as mental disorders. Here, the lack of definitional clarity has become abysmal. Diagnoses such as kleptomania, intermittent explosive disorder, paedophilia, or psychopathy, have been defined on the basis of criminal behaviour patterns and mainly researched among convicted offenders. In order to have them constitute mental disorders, heterogeneous aspects of inner phenomena or cognitions have been assembled into diagnostic designations. By their circular reasoning and limited empirical support from general population studies, these diagnoses have continued to fuel heated controversies about which aspects should be counted as “belonging” to the respective syndromes. It came as no surprise when a recent large-scale meta-analysis of the predictive value of the different “facets” of psychopathy for crimes showed that the strongest predictor was – criminal behaviours (Walters, 2008).

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

Friday, December 19, 2014

Mental disorder is a cause of crime: what is meant by "cause"?

In psychiatric terminology, behaviour is considered an aspect of the mental. The easiest way to deal with the relationship between mental disorder and crime would therefore be just to consider criminal acts to be a form of mental disorder. This stance has never been met with much enthusiasm, however, neither in clinical psychiatry, nor in science or jurisprudence.

Thought of as two distinct phenomena, the connection has been postulated as leading from mental disorder to crime and to be, at least in some respect, causal. At the same time, it is evident that causation in this context cannot mean that mental disorder is a necessary or sufficient cause of crimes.

Modern medicine has increasingly come to work with probabilistic models. Probabilistic theory defines the relation between “risk” factors and effects as an increased probability of the effect in the presence of the risk factor (cf. Reichenbach, 1956; Cartwright, 1979). In our context, probabilism would mean that particular forms of mental disorders are likely to be associated with particular forms of criminal acts. The risk factor may then be assumed to be a (full or partial, see below) cause of the event (meaning that causation is “attributed” to the factor) if there is a temporal relation so that the risk factor can be shown to generally precede the effect, if covariation with other factors (referred to as “confounders”) can be accounted for by logistic or other multivariate statistical models, and if reasonable models are at hand for understanding how the causation operates. 

In other cases, risk factors can be judged to be coincidental to or reflections of common causes. By using probabilism in this way, scientific exploration has been made possible beyond experimental models testing causation. The terms “risk” and “risk factors” are assigned to the cardiologist Dawber (Kannel, Dawber, Kagan, Revotskie & Stokes, 1961) as a model to identify background factors, such as elevated blood pressure, cholesterol, and smoking, behind coronary heart disease. They have become central to medical research and have even come to represent a paradigmatic feature of today's society (Beck, 1992). The concept of risk is therefore a means of avoiding statements of causation, and “explanatory value” in this context will mean “proportion of the variation statistically related to the variation in the risk factor”, which does not necessarily “explain” it in the common, causal meaning of the word.

In the vast majority of those afflicted, mental disorder does not lead to crime. A possible definition of causation in this context would therefore be that a mental factor is a cause of a crime if the mental factor is an insufficient but necessary part of a set of conditions that together are unnecessary but sufficient for the crime (a so-called INUS condition, Mackie, 1965, 1974). Suppose, for example, that a lit match causes a forest fire. The lighting of the match is not by itself sufficient; many matches are lit without bringing about forest fires. But the lit match is in this case a part of a constellation of conditions that together are sufficient for the fire. The match was dropped on a pile of dry leaves, and a gust of wind contributed to the lighting of the fire. Each of the components, the match, the pile of leaves, and the wind, is an INUS condition, each was insufficient, each was necessary, and all together were sufficient for the forest fire, even if other sets of conditions also could have led up to the same effect.

Counter-factuality is thus a prerequisite for a factor to be an INUS condition under the given set of conditions (it should be possible to conclude that “if the mental factor had not occurred or been present, then the crime would not have occurred”, cf. Lewis, 1973; Mackie, 1965, 1974). From this follows manipulability, that it is possible to change the effect or the probability of the effect by changing the cause.

Mackie’s model provides a useful framework to deal with causation behind complex human behaviours such as violent crime. The way we attribute causation even in the sense of INUS conditions in complex chains of events has to be considered. Singling out one of the INUS conditions as the cause of a certain event is often a matter of choice and not based on rigorous scientific investigations. Since each factor, by definition, forms a necessary part of the overall condition, we do not really have any grounds for pinpointing one of them as contributing to the effect to a higher degree than the others. 

Human minds, however, strive to attribute causes in order to be able to predict what will happen in the future. Only in very rare instances are such attributions of causation based on experiments or strict, logical deductions. As the factors that may be shown to cause human actions in the INUS sense are invariably numerous and interact in complex constellations, the way we identify causes and assign importance to them is in itself the object of psychological research (Cheng, 1997).


As for crime and punishment, there is every reason to believe that mental disorders attract undue attention among possible explanatory factors. Generally, we have a strong tendency to assign causation of undesired events to factors that are strange or exotic in relation to ourselves, classically to other ethnic groups or to people with features that in one way or the other make them different from us. This powerful force directs our attention towards mental disorders among all the possible INUS conditions that may be discerned in the background to a crime. 

In forensic psychiatric research and expert opinion, the attribution of causation has no doubt been influenced by ideas developed within the professional psychiatric paradigm. And for the causation that is to be judged by the lawyer, counter-faction will be non-informative. How could any mental condition (i.e. inner experiences, cognitions, and/or behaviour patterns) be ruled out as a contributing factor in the very complex sets of factors influencing human action?

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

Friday, December 12, 2014

Mental disorder is a cause of crime: the jurisprudence perspective

From the legislators’ point of view, the assumption that there may be a causal connection between mental disorder and crime has major consequences. Almost all countries consider accountability a requisite for punishment, and mental disorders are virtually the only legally acceptable factor that can be used in a defence claiming reduced accountability or insanity. 

The role attributed to mental disorders ultimately depends on the guiding aims of penal law. Justice may be understood as the establishment of guilt or as some form of equalling out wrongs, whereas modern penal systems serve several, partly conflicting, goals. If retribution is the goal, reduced accountability due to mental disorder must be considered as humans have unequal chances of refraining from crime (Rhee & Waldman, 2002). If the goal instead is crime prevention (through treatment, incapacitation, deterrence, or combinations thereof), sanctions have to be devised in relation to the risk of criminal recidivism and their scientifically documented, preventive effect. 

Factors that would be considered mitigating in the context of retribution (such as youth, poor social integration, impulsivity, deficits in other mental faculties) may instead call for harsher preventive measures, such as long-term incarceration or intensive societal surveillance. 

Every attempt at implementing a purposeful societal approach to criminal offenders would thus require a clearly stated aim, or combination of aims, for the penal law. If the legislator wants the system to fulfil several aims, it has to be clearly stated what these aims are and what their relative priorities should be when conflicts ensue. No system could fully serve each and every aim. 

The lawyer’s perspective is focused on the procedures of the judicial process. In the individual case, the causal role of a mental disorder behind a crime has to be determined, and the normal requirements of justice, such as equality, predictability, and transparency, have to be upheld. Lawyers must know what expertise to ask for and exactly what type of knowledge the different experts can provide. They must also be familiar with the grounds for questioning expert opinions and seek a second view, or with how to challenge a testimony presented in the courtroom. 

At the end of the day, it is also lawyers who will have to evaluate the causal relation between the psychiatric problems diagnosed and the crime committed. “Beyond any reasonable doubt”, the normal standard of certainty in law, has to be accommodated to the lesser precision of the clinical judgment of psychiatrists.

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

Friday, December 5, 2014

What is a mental "disorder" (part 3): validity of diagnoses according to the Robins & Guze criteria (1970)

In psychiatry, validity has mostly been an issue when determining how “validly” a diagnostic instrument may identify a categorical diagnosis. Comparatively less attention has been focused on the validity of the diagnostic constructs. 

A few leading psychiatrists have developed criteria for the validity of disorders (Andreasen, 1995; Kendell & Jablensky, 2003; Kendler, 1980; Robins & Guze, 1970). Robins and Guze argued that psychiatric diagnoses should be based on systematic studies instead of “a priori principles” and defined five areas in which such studies should be carried out: 1) systematic clinical descriptions, 2) laboratory studies, 3) delineation from other disorders, 4) follow-up studies, and 5) family studies. 

Kendler (1980) added that diagnostic validity should require follow-up studies showing diagnostic consistency over time, similar rates of relapse and recovery, and homogeneous response to treatment, while family studies should show aggregation of similar symptom constellations among relatives. 

Andreasen (1995) declared that psychiatry had reached the stage where it was now “founded on diagnoses that are validated by clinical description and epidemiological criteria” and called for a “second structural program for the validation of psychiatric diagnoses” based on “methods that are being applied to track mental illnesses back to the organ system from which they emanate, the brain, and to the aberrations occurring at a molecular level in DNA”. 

Kendell and Jablensky (2003) attempted to emphasize the scientific basis for diagnostic classifications by separating validity from utility. They suggested that diagnostic categories “should be regarded as valid only if shown to be discrete entities with natural boundaries that separate them from other disorders” or from normality by a “zone of rarity”, or if defining characteristics, such as chromosome or biochemical abnormalities, delineate the diagnosis from other conditions with similar symptoms, and concluded that “most diagnostic concepts have not been shown to be valid in this sense”. 

When the DSM-5 was published in 2013, a wider public debate on the validity of psychiatric diagnoses ensued. The field trials had shown very poor test-retest reliability and prevelences for some disorders varied considerably by small changes in diagnostic criteria, such as the age when symptoms of ADHD should first have been apparent (as detailed in books by, among others, Greenberg and Frances). The NIMH then suggested an alternative model that allowed also subsets of functions and symptoms but required theoretical and/or empirical co-variates for each problem type (RDoC). In these debates, validity of diagnoses was often referred to as validity of assessment, and vice-versa. 

It may therefore be useful to go back to the original Robins and Guze criteria and re-assess them in view of recent empirical findings.


Clinical validity (Robins and Guze criteria 1 and 3)


Considering what we now know about the epidemiology of mental health problems, it is obvious that what Andreasen expected in 1995 has not come about. First, no mental disorder (besides mental symptoms induced by medical diseases, such as Huntington’s chorea) has yet been statistically distinguished from the normal variation by a “zone of rarity” or shown to constitute a “taxon” among other problem types in the population variance (Cloninger, 1999). Instead, the notions of “broader phenotypes” or “sub-threshold” disorders (initially described in relatives of probands in genetic research) and “spectra” of “overlapping” or “comorbid” disorders, have gained wider acceptance. 


Laboratory “markers” (Robins and Guze criterion 2)


Findings from the laboratory have provided no further support for the categorical system. Andreasen (1995) noted that the “markers” required by Robins and Guze “had not emerged” and that they had rather “risen and fallen” (e.g. the dexamethasone suppression test for depression), but her confidence in the development of new methods, such as brain imaging and molecular genetics, remained unbroken. Findings from studies using these increasingly sophisticated technical methods, however, have been at least as difficult to replicate, and/or as unspecific in relation to diagnostic categories, as those produced by the older models. Reports on new technologies to differentiate between a (small) group of patients and controls abound in the scientific literature, but no method with diagnostic specificity in relation to other problem types has yet been established.


Longitudinal follow-up (Robins and Guze criterion 4)


Research on longitudinal diagnostic stability is impeded by the artefactual hiatuses caused by the division in child- and adolescent psychiatry vs. adult psychiatry at about age 18, or in adult general psychiatry vs. “neuropsychiatry”. Child psychiatric conditions are often interpreted in terms of cognitive disabilities rather than disease, even in conditions for which medication is the standard treatment. With increasing age, definitions subsequently become more influenced by adult designations of symptoms, introducing concepts such as “paediatric” mania or “prodrome” schizophrenia. To what extent these clinical conditions really correspond to similar conditions in adulthood has not been established, but differences in symptom presentation and treatment responses seem to differ (e.g. SSRI treatment of depression in adolescents, Weller, Tucker, & Weller, 2005), and heterotypical progressions of problems from childhood into adulthood are the rule rather than the exceptions (Hofvander, Ossowski, Lundström, & Anckarsater, 2010).
Nor do longitudinal treatment effects seem to respect diagnostic categories. Pharmacological remedies alleviate symptoms across diagnostic divisions, no matter if their target is specific or wide. Lithium stabilizes mood in borderline personality disorder just as in bipolar disorder, atypical neuroleptics tranquilize, and serotonin reuptake inhibitors influence mood and anxiety regardless of diagnostics (Kramer, 1997). Psychotherapies and psychosocial interventions also have effects across diagnostic categories.


Familial aggregation (Robins and Guze criterion 5)


Familial aggregations of disorders have been studied by epidemiological methods to assess the overall importance of heritable factors for the variance in psychiatric phenomena. Family and adoption studies, not least twin studies, have provided ample support for the notion that hereditary factors play important causative roles in the variation of all mental health problems and associated features (Rutter & Silberg, 2002). This strand of research has used categorical as well as dimensional definitions (Levy, Hay, McStephen, Wood, & Waldman, 1997). More recent twin studies also collect data on co-existing and interacting problem constellations (Lichtenstein, et al., 2009) and follow developmental trajectories from adolescence (Silberg, Rutter, Neale, & Eaves, 2001) into the adulthood disorders (Cardno, Rijsdijk, Sham, Murray, & McGuffin, 2002; Kendler, Gardner, Annas, & Lichtenstein, 2008; Kendler, Gardner, & Prescott, 2003). Separate aetiologies have been reported for features previously linked into syndromes (Ronald, Happe, Price, Baron-Cohen, & Plomin, 2006), and conceptually different facets of clinical problem constellations have been found to have aetiological factors in common (Larsson, Andershed, & Lichtenstein, 2006).

Conclusion


None of diagnostic labels in use today meet the Robins & Guze criteria for validity. Psychiatrists are reluctant to recognize this, and often intertwine "valid assessments" with "valid diagnoses". A possible way forward would be to define "mental disorder" on the level of functioning and/or subjective suffering only, and then pursue research on symptom complexes, their aetiology and how they respond to treatment. Treatment efforts aimed at improving global functioning may also be evaluated on more relevant measures than reductions of some specific symptom cluster. But recognizing the lack of scientific validity for today's diagnoses may have far-reaching consequences for their use in legal contexts. 

This post is partly excerpted from Anckarsäter H. Beyond categorical diagnostics in psychiatry: scientific and medicolegal implications (2010). Should someone need a full-length manuscript or a reference list, don't hesitate to contact through the blog or e-mail henrik.anckarsater@neuro.gu.se. 

Friday, November 28, 2014

What is a mental "disorder" (part 2): two viewpoints on mental health problems

Largely, there are two conflicting views of mental health problems. Others might be listed, but these perspectives provide two images that are difficult to merge. Yet they may depict the same phenomenon. 

The first sees mental health problems from the viewpoint overlooking those very seriously affected. This group has lives in tatters due to their problems. They may be intellectually disabeled, suffer major psychotic disorders, paralyzing mood or anxiety problems or drink in a perfectly obsessive way to an early death. 

Noone has any difficulty saying that these persons are ill, nor that abnormal brain functioning is involved. General movements and posture are affected. It is debated whether this kind of mental illness is on the rise or remains constant across cultures and time, but anyway, prevalences are counted in single-digit percents. Proponenets of this perspective are often psychiatrists or nurses.

The other sees mental health problems from the viewpoint of total population epidemiology. This is a different sight. Problems are now present in tens of percents of the population, are gradual rather than categorical, change over time, often into new diagnoses or no diagnosis at all. Instead of disease-like conditions, diagnoses may be worded as liabilities or traits, and understood rather as extremes in the normal variation than as pathologies.

The problem is that psychiatry, in the era of criteria-based diagnoses, has put very little effort into studying how these two views relate to eachother. Instead, both have been voiced as if they were one and the same seamsless psychiatric truth. There is vast clinical experience to validate the first, in addition to it being common-sensical. There is more and better scientific data to validate the second.

Problems arise when knowledge from the first group is applied to large swaths of the population. Substance abuse is one example. Psychiatrists are eager to promote a medical model based on the very severe cases, but this conflicts with population-based data showing that most cases remit spontaneously, even without treatment. Maybe the same problem is present in our understanding of depression, hyperactivity, autism spectrum disorders, behaviour disorders and even psychoses?

This would explain why findings of brain abnormalities, genes and treatment effects in case-control studies tend to disappear when tested in population-based studies. And how 80% of the liability for a certain condition may be statistically referred to genetic effects, while the gene variants actually found only have very small effects. It also means that the severe cases may not be fully understood from the general population viewpoint, and that, if a clinical group with schizophrenia or autism have a certain sign in their genome or brain scans, it cannot be interpreted as a characteristic for the type of problem in the population.

It is tempting to propose that the general population liability for mental health problems expresses genetic polymorphisms, while the severe cases are due to mutations. In some very crude way this may be true, for example in autism, where mutations have been found in subgroups of cases who often also have mental retardation. And as polymorphisms are defined as being more prevalent than mutations, it would seem a safe bet. But as a general explanation, I think such analogies between genome and mental phenotypes over-simplify the complex causation of mental health problems. They also overlook how mental processes may be free, random, self-generating and the result of interactions with the environment.

In a forensic or moral context, the obvious existence of persons who have had their mental capacities for insight and action control destroyed by severe mental or neurological disorders should not be interpreted as a general lack of accountability in people with mental health problems. As health care staff, our aim should be to restitute health and responsibility. By stating generally that people with e.g. substance dependence or ADHD have no responsibility for their behaviour, we disserve large numbers of persons who deserve both praise and criticism for their acts.

Elegant plaidoyers of the first vs the second view are proposed by Allen Frances in "Saving normal" and by Jonathan Rottenberg in "The Depths". Both books are heartily recommended.

Friday, November 21, 2014

Mental disorder is a cause of crime: what is a "disorder" in this context? Part 1

Psychiatry is not only vague in defining the "psyche" (a.k.a. the mind, the spirit) but also in how to name its pathological states. In the DSM-IV-TR, we read that “each of the mental disorders is conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual” (APA, 2000, p. xxxi). 

Numerous other terms, more or less synonymous with “mental disorder”, have been suggested, e.g. “illness” or “condition”.

"Clinically significant" may mean that the condition hampers the ability to "work and love" (Freud), i.e. to have meaningful occupation and relations, but also that the condition produces considerable suffering. Various definitions of mental (un)health have been proposed, but none is generally accepted. 

Mainstream psychiatric texts use the term “mental disorder” as a compromise. The stated advantages are that the term is unspecific about non-physical entities, such as the soul, and about the aetiology of problems, such as in illness. 

“Disorder” is a broadly defined term. It indicates a lack of some sort of order but does not specify what that order is. 

Is a mentally disordered person someone who in some mental aspect lies outside the variation contained in the central standard deviations of the normal curve? Or does (s)he fail to live up to an ideal, ordered, state of mind? Or does (s)he present symptoms that are qualitatively different from what is experienced by healthy persons (such as hallucinations, delusions, tics, or compulsions)? 

All three definitions are open to justified criticism. Symptoms such as hallucinations are not limited to persons exhibiting other features of mental disorder (van Os, Hansson, Bijl & Ravelli, 2000). Dysfunction and suffering depend to a considerable degree on the environmental demands made on an individual, and deviance from the average may be both advantageous and disadvantageous (Baron-Cohen, 2000). The statistical approaches invariably include measurement problems.

Of course, this vagueness becomes most problematic when definitions of mental disorder are applied in courts of law, but they also haunt psychiatric research. We will therefore continue to go through definitional pit-falls and different systems of validating disorders in a few more posts. Next week, the two different views on mental disorders as illnesses in the medical sense vs. extremes of the normal distribution will be discussed.

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

Friday, November 14, 2014

The mind and the body in (forensic) psychiatry

Throughout the history of human thought, few other distinctions have evoked so much controversy as the one between the mind and the body. In the DSM-IV-TR, it was regretted that the term “mental disorder” emphasizes mental as something distinct from physical, which is regarded as an “anachronism of mind/body dualism” (APA, 2000, p. xxx).

Causation is key to understand the relation between the mind and the body. The body influences the mind (most clearly shown by drug effects), but the jury is still out on whether the mind can influence the body. 

Material determinists deny that it can, mainly based on the lack of a reasonable mechanistic explanation. 

Bi-, or rather multi-directional causation body>mind>body>mind etc, is, however, indicated by e.g. real-life experiences of acts of will, the placebo effect and the influence of expectations on health.

This conflict partly stems from epistemology. The mind is considered in terms of “experience”, “knowledge”, and “being” that are distinct from how the brain and its physiological processes are conceived of. Different types of knowledge are difficult to join in a common model, even if the clinical psychiatrist approaches a person who happens to have a body and a mind.

And different ways of aquiring knowledge do not exclude that information refer to the same underlying phenomenon. 

Just as a notion of beauty may be applied to the same body that is scientifically examined as an organism, and perhaps to some extent even be causally determined by it (correlations between notions of beauty and physiological processes may be assumed), it is obvious that notions of beauty and of physiology operate according to different epistemological premises. The means by which we decide upon aesthetical matters are not the same as those we use in the natural sciences, nor are the concepts used in the different contexts inter-translatable in a straight-forward sense. The use of a plurality of concepts and methods does not in itself imply a plurality of real world items.

In order to meet medical or legal definitions, mental disorder are thought to refer to the form (processes, abilities) rather than the content (subjective experiences, as defined by Jaspers). The form is intuitively thought of as being more "brain-based" than the content. 

This remains an attractive idea. It is a common assumption in psychiatry that there are "real" mental disorders rooted in cerebral malfunctioning, and other, less severe conditions, which are more related to the person and her choices, life-style and experiences. 

But from the perspective of neuroscience, it makes little reason to think that one mental problem should be less "brain-related" than another. The body and the mind are intrinsically linked, mysteriously even.

The epistemological framework of psychiatry does not produce the concepts or the data that can give an answer to what is freely willed, morally good or bad. Science studies regularities, and acts of free will are unpredictable. Therefore, notions that presuppose freedom (such as evil) escape scientific explanations. Needless to say, this does not prevent the consequences of mental processes, e.g. behaviours, to be objectively good or bad.

As long as we do not know how the body and the mind interact to create a human person, nor whether determinism is true or there is a causal effect of free choices, scientific expertise for courts should be carefully worded to express what we know and what we don't know, and to refer to the findings of assessments rather than to legal or moral definitions that presume free will.

Medical conditions can preclude free choice and insight, but medicine cannot say that a specific act was done freely. This does not mean that a judge can't.    

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. 

Friday, November 7, 2014

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. 

Tuesday, November 4, 2014

"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)