© 2015 Bill Eddy, LCSW, Esq.
We live in an age of overlap between legal and mental health problems. It is frequently said that there are more people with mental health needs in our legal systems than in our mental health systems. Recent news events have emphasized mass shootings by those with mental health problems, workplace conflicts which become violent and police encounters with the mentally ill – which sometimes end in the death of the mentally ill person or the police. In family court cases, workplace disputes and community conflicts, mental illness is frequently cited as a major factor in incidents of violence.
Yet despite all of this talk about mental health problems, there seems to be little discussion of what mental illness really is. In reality, there are many different types of mental illness, some more dangerous than others, and some more identifiable than others. This article attempts to give a brief overview of some of the basic mental disorders in terms of general violence risk and why everyone needs to understand these problems better – and to support efforts for more professional training and more services for those with mental health needs.
The following information is drawn from my general knowledge as a therapist and family lawyer, and from the manual of mental disorders used by mental health professionals: Diagnostic and Statistical Manual of Mental Disorders, fifth edition (2013), published by the American Psychiatric Association – commonly known as the DSM-5. You should not attempt to diagnose someone based on this information, but rather seek the assistance of a licensed mental health professional for evaluation and treatment.
Depression has a wide range, from situational temporary depression such as over the loss of a close friend or relative, to mild chronic depression, to major depression. The DSM-5 says that approximately 7% of the population will suffer from major depressive disorder in any given year, which means that they have depressed mood most of the day, almost every day. This includes feeling sad, hopeless and discouraged. Fatigue and insomnia are common. In children and men, this may take the form of irritability rather than sadness – yet still be depression.
Some people have suicidal thoughts with depression, while others do not. Depression mostly drains the energy from the person, but some become energized as they are coming out of a depression and take action to harm themselves. Men, more than women, have agitated depressions which may give them energy for self-destructive acts. In rare cases, they will harm others while ending their lives, such as in a murder-suicide. However, I personally believe that the people who do this also have a personality disorder (see below). In general, depression alone appears to make one less likely to hurt others, rather than more likely. Depression is a fairly treatable disorder, with medications, counseling or both.
Anxiety is generally characterized by extra caution or avoidance of perceived threatening situations. Anxiety also has a wide range of intensity. More severe forms include social anxiety disorder, which the DSM-5 says occurs in any given year for about 7% of the adult population, generalized anxiety disorder for about 3% of the population and panic disorder for 2-3% of adults. These tend to cause an overall decreased sense of well-being, sometimes to the point of dropping out of school, losing a job, avoiding dating and over-compensating with drugs and alcohol. Generally, they are more afraid of confronting others rather than acting out aggressively. Anxiety disorders are also fairly treatable with therapy, medications or both.
Bipolar disorders take several forms, which are each described in the DSM-5 and add up to about 2% of adults. They appear to be more genetic – a biologically-based chemical imbalance – and cause the person to have manic episodes (for a week or longer) when they are extra energized most of the day, don’t sleep much, are extra talkative, distractible and enthusiastically engaged in activities that may hurt them in long run (sexual indiscretions, over-spending, etc.); followed by depressive episodes (two weeks or more after a manic episode), when they demonstrate the sadness, hopelessness and reduced energy described above for people who suffer depression.
While people with bipolar disorder are sometimes known for their wild behavior, during the manic episode there is also an increased risk for violence. On the other hand, their suicide risk to themselves is much higher than the general population and the DSM-5 states “bipolar disorder may account for one-quarter of all completed suicides.” Medications are the basic treatment approach for the bipolar disorders, because they appear to be primarily a bio-chemical problem.
This disorder is poorly understood by most people, because it is so rare. Only about 1% of the population has this disorder, which is marked by psychotic symptoms, such as hallucinations (hearing voices that aren’t there) and delusions (seeing people or having beliefs that are not based in reality). While this disorder is often mentioned with mass shootings, people with schizophrenia are generally no more violent than the average population and that was my experience working with them in psychiatric hospitals. When we hear about someone with schizophrenia being involved in a mass shooting, I believe that it is because they also had a personality disorder (see below), not because of the schizophrenia. However, in very rare cases they may have “command hallucinations” which order them to kill someone. Schizophrenia is often what people think of when they think of mental illness.
Substance Use Disorders
Alcoholism and other chemical addictions are a common problem in the United States. They are characterized by denial that there is a problem and continued use even when the substance causes increasing problems in relationships, employment, finances, health and other areas of one’s life. The DSM-5 states that alcohol use disorder occurs in about 8.5% of the adult population in any given year. Adding in all the other substance use disorders, including addiction to prescribed medications, there may be as many as 15% of adults meeting the criteria for a substance use disorder of one kind or another. Various substances can have a significant effect on someone’s behavior, from putting them to sleep (heroin, sleeping pills, etc.) to making them extremely aggressive (methamphetamine, cocaine, PCP, etc.). As most people know, substance abuse can potentially make anyone dangerous, including suicidal and/or homicidal behavior. While illegal drugs get the most attention, alcohol is by far the most common cause of death of any substance in our society – especially drunk driving – which far exceeds gun violence in America.
This is the category of hidden mental illness. While the other mental disorders may be generally obvious (people look depressed or anxious; act bipolar; look/smell under the influence; talk to their voices; etc.), personality disorders are generally not obvious. They look like everyone else and they are not obviously uncomfortable with themselves. They’re more upset about how they are treated by other people and may be preoccupied with blaming others for various problems in their lives. In essence, personality disorders are interpersonal disorders.
Unlike the other disorders, people with personality disorders don’t think they have a problem. In fact, that’s one of their key characteristics: 1) They lack self-awareness of how they create many of their own life problems. 2) They don’t change their own behavior, because they don’t think they need to. 3) They think that others cause their problems and some of them are intensely preoccupied with blaming specific others – their targets of blame. I believe their tendency to intensely blame certain people is what leads some of them to commit violence against others without empathy or remorse.
The criteria for one personality disorder in particular – antisocial (sociopathic) personality disorder – includes “lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.” Also, they may be arrogant, “excessively opinionated, self-assured or cocky.” (DSM-5, p. 659-60.) From my observations, they often appear to enjoy hurting others and are driven to dominate others – especially those in much weaker positions. They also enjoy risk taking and conning others.
The role antisocials play in the workplace, communities and terrorism seems to be significant, as they will say anything and play the role of victim in order to seduce people into their schemes. They can be the most charming personality of all – as well as the most dangerous. They should not be underestimated. I believe they play a substantial part in the public violence we are seeing these days around the world.
Borderline, narcissistic and paranoid personality disorders also include an increased incidence of violence for some (but not for many others) when they feel abandoned, humiliated or betrayed. Their dynamics are more likely to appear in domestic or workplace violence than in public violence, which appears to be primarily the domain of antisocial personalities.
The DSM-5 says that approximately 15% of the U.S. population meets the criteria for a personality disorder. Antisocial personality disorder is considered to be up to 3-4% of the population according to the DSM-5, and much more common in men. Narcissistic personality disorder is present in about 6% of the population, borderline personality disorder is present in about 6% and paranoid personality disorder is present in 4-5%, with some overlap among these and other personality disorders.
Other Mental Disorders
There are several other disorders in the DSM-5, but they are less likely to be associated with violence. For example, there are eating disorders, autism spectrum disorders, obsessive-compulsive disorders, sexual dysfunctions, and neurocognitive disorders (like dementia).
This is just a brief look at various mental health problems and their general relationship to violence. Many with one disorder may have another disorder as well, such as a personality disorder and depression or anxiety and substance abuse. Professionals, friends and family members need to become more educated about these as they appear to be present in more and more conflict situations in modern life. It is very important to be aware of those who are more dangerous, but also important not to judge or stigmatize people with other mental disorders who may be no more dangerous than the average person.
BILL EDDY, LCSW, ESQ. is the co-founder and chief innovation officer of the High Conflict Institute. He pioneered the High Conflict Personality Theory (HCP) and is viewed globally as the leading expert on managing disputes involving people with high conflict personalities. He is the author of 20+ books and has a popular podcast and a blog on Psychology Today.