Misconceptions About Psychiatric Disorders

I just got my deposition taken, in connection with an assault case that is going to trial next week. I am serving as a forensic psychologist, and expert witness for the defense. Getting deposed usually gives me the chance to be exposed (again) to the persistent misconceptions that many people (and, especially, prosecutors) harbor about "mental illness." So I will make a list of the top several of these:


My (current) Top 4 Misconceptions about Psychiatric Disorders:


1. People with a mental disorder always behave in a way that appears obviously "crazy" to any outside observer. Prosecutors like this one because they can always point out instances in which a person with a psychiatric diagnosis can be demonstrated to have done something very ordinary and apparently rational, such as getting up in the morning, and putting on clothes. They like to try to use these little examples to undermine a psychologist or psychiatrist who diagnoses the person with (for example) major depressive disorder, or bipolar disorder, or delusional disorder. The truth is, of course, that psychiatric diagnoses come with various symptoms, at various levels of severity, and causing various amounts and types of disability. Most people with any of these (severe) disorders are NOT totally disabled, even throughout the entire course of the active phase(s) of their disorders.

2. People with a mental disorder are unable to have any rational thoughts. This is related to Misconception #1, above. Let's say that a person with schizophrenia truly believes that his wife has become the devil, and is about to kill him; under the influence of this belief, he shoots and kills her, and then runs away and hides. Prosecutors (and a lot of psychiatrists who work for the government) will (sometimes triumphantly) label the running-away-and-hiding behavior as "consciousness of guilt," and "understanding that what he did was wrong." Not necessarily. It is (at least) equally likely that the person believes that he did the right thing, out of necessity, but is afraid that others will not understand, and will blame him.

3. People commit crimes for reasons that are either totally "sane," or totally "insane." Human behavior is much more complex than that; the presence of a serious mental disorder may very well have a significant impact on a person's thinking, emotional functioning, and behavior. But that doesn't mean that there may not be other factors involved in the behavior, as well, and these factors may not seem all that "insane." The psychiatric symptoms may easily exist right alongside a capacity for rational decision-making, as well as normal motivational factors, and all of these factors (along with various unpredictable stimuli from the environment) will combine, producing behavior that might differ tremendously from the behavior that might be anticipated in that person if the psychiatric symptoms were not present, and part of the mix.

4. Psychiatric diagnosis is an exact science. Not so. The diagnostic manual (DSM-IV-TR) offers an illusory appearance of exactitude and precision. The real situation is much, much murkier. Although some conditions are easy to diagnose, and easy to distinguish from other conditions, there are many other conditions and diagnoses about which reasonable and well-trained doctors will disagree; and there are many conditions/diagnoses that are not at all easily distinguishable, one from another. Finally, various conditions have a course that changes in its presentation over time, making it difficult, for example, to distinguish between Paranoid Personality Disorder, and Delusional Disorder (Persecutory Type).



So: what I am often trying to convey to a jury (and trying to explain to prosecutors, although they don't want to hear it) is this: a person may very well commit a criminal offense due to the influence of a serious psychiatric disorder, while nevertheless appearing relatively "normal," to the untrained eye. In other words: In order to be legally found not mentally responsible for his behavior (legally "insane"), he need not be raving about nonsense all the time, running around naked, incapable of rational conversation, seeing things that are not real, or totally out of control. Usually, it is not that way, at all.