On June 25, 2022, in the wake of the Uvalde mass shooting, Joe Biden signed a gun bill to limit who can purchase firearms. In addition to more extensive background checks, the new law directs funds to community mental health services and expresses commitment to improving the mental health of school-aged children.
Psychiatry has always walked a fine line between cure and control, care and coercion, consoling and classifying. What we see currently, post-Uvalde-tragedy is a conversation that tends to focus less on the lack of adequate infrastructure to support education, care, and treatment of youngsters and more on the need for early detection of “underdiagnosed” and “undermedicated” disturbed individuals.
While in other fields of medicine, the correct diagnosis informs treatment decisions, psychiatric diagnoses cannot offer such a clear account of problems or treatment. Moreover, history shows that psychiatric diagnoses rise and fall according to our ever-changing social, cultural, and historical conditions. The danger is that these diagnoses wield disproportionate influence once created, and doctors are inclined to use them even when they doubt their validity.
During the last decade, the psychiatric guide for classification of mental disorders, DSM-5has come under a major attack from within the psychiatric establishment and philosophers, advocacy groups, patients, and their families.
In 2013, in a public announcement, the National Institute of Mental Health (NIMH) encouraged researchers to drop old DSM diagnoses and search for valid measures for mental disorders, now seen as brain disorders. Funding has since been directed to searching for presumably “real” diseases in our genes, cells, and brain circuits, but no alternative classification system has yet been found. As a result, clinicians still label their with the old diagnostic names for mental illnesses.
Retroactively diagnosing mass-shooters or using the DSM diagnoses to target those who might become offenders not only stigmatizes thousands of people (most of them individuals who are more likely to be victims of violence), it also assumes that our system of psychiatric classification is stable and valid. Yet our classificatory system has never been set in stone. To give a telling example: Asperger syndrome, a diagnosis given to the Isla Vista, California, shooter, no longer exists; It has been replaced by the new diagnosis of autism spectrum disorder (ASD). In other words, since 2013, there is formally no more “Aspergers” among us; Thus, we cannot identify them, treat, or medicate them.
Schizophrenia, the diagnosis assigned to the Aurora, Colorado, movie-theater shooter and the shooter at Sandy Hook elementary school, has a similar history. As a diagnosis, it was first introduced by the Swiss psychiatrist Eugen Bleuler in 1908 and has since shapeshifted remarkably. It was originally conceived as a group of various disorders, and neither danger to others nor physical violence formed a central aspect of the diagnosis.
Adolf Meyer’s more holistic model influenced the first edition of the DSM in 1952, and instead of diagnosing “schizophrenia,” it classified the different “schizophrenic reactions.” It was believed that schizophrenia was not a chronic, incurable illness but a reaction to bio-psycho-social stressors.
Only during the 1970s was schizophrenia seen as an illness (not a “reaction”), and American society began to link schizophrenia with violence and guns. As Jonathan Metzl has shown in his book The Protest Psychosisit was precisely in the context of the Civil Rights movement that schizophrenia also became a “Black disease,” and African American men have since been diagnosed with this disorder three to four times as often as others.
Since the 1980s, schizophrenia has been believed to be a brain disorder.
Due to the lack of convincing clinical findings that could determine whether there is such an illness that could accurately be diagnosed (in much the same way that pneumonia or diabetes could be), DSM-5 placed schizophrenia on a large spectrum of mental phenomena. A strong lobby, led by doctors and patients, is also trying to abolish the word schizophrenia altogether and follow the Japanese example of changing the stigmatized name with the diagnosis of “integration disorder,” a change that proved beneficial to both patients and doctors.
But the problem runs deeper than just names of diagnoses: In the shift from categorical diagnoses to spectrums, ranging from at-risk conditions to severe mental illnesses, we have further witnessed a troubling “diagnosis creep.” Many more people are being offered a psychiatric diagnosis as much milder conditions fall under large new spectrums of pathology.
While the “at-risk” individuals we aim to diagnose with our ever-changing classification tools have become de facto moving targets, our school children remain sitting ducks.
As a clinician and parent, I find that inevitable conclusion outrageous and unacceptable. I was only four years old when I first had to take shelter in Israel during the Yom Kippur War; my older daughter was six years old when she had to carry a gas mask every day to school in Tel Aviv during the Iraq War.
I find it hard to stomach that my born and raised American daughter has more chance than most other children in the world of being harmed by a weapon of war–in the United States. Astonishingly, many legislators think that the problem of mass shootings lies within the rare individuals whose fingers pull the trigger. People do suffer in ways that make them exceptionally violent.
Still, the assumption that information about their psychiatric diagnosis would close one major loophole in the efforts to prevent these unfathomable tragedies is ill-informed and politically misguided.
Instead of relying on psychiatry’s ever-extending “empire of diseases,” we should concentrate on treating the single most crucial underdiagnosed madness: that of selling semi-automatic assault weapons to civilians.
This, next to investing government resources in building and sustaining infrastructures for education and public health, as well as reasonable social policies, will secure the care and opportunities for growth for those in psychological need.