Is the killer crazy, or just mislabeled?

by Sandra Parshall

Crime fiction writers throw around words like psychotic and sociopath a lot, although we often seem to need reassurance that we correctly understand the difference. We like to feel confident describing a crazed killer who wears an aluminum foil cap as paranoid schizophrenic. If we’ve done our research, we know the definitions and we know which illness might produce criminal behavior.

But things are about to get confusing. This time next year, the American Psychiatric Association will publish the first major revision in thirty years to the Diagnostic and Statistical Manual of Mental Disorders. Psychiatrists will be expected to revise their approach to diagnosing patients – and mystery writers may have to be more careful about the terms we use, especially if we put them in the mouths of characters who are supposed to be experts.

Some major disorders will vanish altogether. Among these are several useful “personality disorders”: histrionic, paranoid, dependent, and schizoid. Symptoms of these “disorders” are so common in the general population that the APA has decided they can’t be classified as illnesses. Remaining in the manual are the narcissistic, antisocial, avoidant, borderline, obsessive-compulsive, and “schizotypal” personality disorders.

Asperger’s syndrome will be eliminated as a distinct diagnosis and folded into the broad category of autism spectrum disorder. Even high-functioning people currently diagnosed with Asperger’s – those who are self-supporting and interact well with others – will be labeled autistic. Critics of the change worry that if the diagnosis of autism is made early in life, it could affect the child’s educational opportunities and, later on, his ability to find a job. At the same time, resources needed for severely autistic children might go to students who don’t need them.

For the first time, the DSM will categorize certain compulsions, such as binge eating, gambling, and uncontrollable sexual desires, as addictions. Scans have shown that the “reward circuits” in the brain of an addict will light up at the very thought of the addictive substance, whether it’s drugs or gambling. 

The diagnosis of childhood bipolar disorder will be replaced by disruptive mood dysregulation disorder. Although it is extremely rare for anyone under twenty to develop true bipolar disorder with mood swings, diagnoses have increased 400% in the U.S. since 2000. The new term better describes what’s happening with these children: constant anger and irritability, explosions of violence, without the sublime highs that characterize bipolar disorder. Critics of the new label are afraid pediatricians will apply it to any child with a grumpy personality who is prone to tantrums. The new diagnosis, like that of childhood bipolar disorder, could lead to drugging kids who aren’t mentally ill with powerful mood-altering drugs that come with dangerous side effects. (Some doctors believe that getting these children off sugar and food additives is the remedy.)

Another controversial new diagnosis is “attenuated psychosis syndrome,” intended to identify children who might be on their way to full-blown psychosis. Again, the fear is that kids who aren’t mentally ill, and might never be, will be “treated” with powerful drugs as a preventive measure that isn’t warranted.

Despite the protests, the APA believes the revised guidelines will result in more precise diagnoses and better treatment. Psychiatrists and other mental health professionals won’t have much choice about following the DSM guidelines, because insurance companies are likely to deny coverage of an illness that doesn’t conform to a DSM definition.

So what will crime fiction writers have to work with when therapists change the way they diagnose people? If a killer wants to blame his crime on mental illness, what can a psychiatrist say in his defense? Never fear; we still have a lot to choose from in the new DSM’s section on psychosis:

Schizotypal Personality Disorder
Delusional Disorder
Brief Psychotic Disorder (that old standby temporary insanity)
Substance-Induced Psychotic Disorder
Psychotic Disorder Associated with Another Medical Condition
Catatonic Disorder Associated with Another Medical Condition
Schizophreniform Disorder
Schizoaffective Disorder
Schizophrenia
Psychotic Disorder Not Elsewhere Classified
Catatonic Disorder Not Elsewhere Classified

The proposed text of the revised DSM is online here. The site has been visited more than 50 million times already and drawn more than 10,000 comments.

Speaking of getting it right when you create a psychotic killer, mystery author and practicing psychotherapist Dennis Palumbo believes that too many authors don’t do enough research to make their villains convincing. Instead, they use boilerplate language to produce characters who are “mindlessly, conveniently crazy” and sometimes not the least bit scary. Dennis has some good advice for writers in a Huffington Post article that asks, “Is your psycho killer just... psycho?” Read it here.