Part I: Mental Illness, Firearms, And Violence
January 31, 2019
Authors: John Malcolm and Amy Swearer
This is Part I of a three-part series of papers examining the intersection of mental illness, violence, and firearms. As the nation sits in the midst of a serious discussion about gun violence in general, and mass shootings in particular, we must ensure that policy decisions regarding Second Amendment rights reflect an accurate understanding of the role mental illness does and does not play in gun violence, as well as an accurate understanding of why the United States is suffering from a crisis of untreated serious mental illness.
Policies aimed at protecting the public from mass public shootings must not overlook the role of firearm access by individuals with serious mental illness.
Such policies must also take, however, a holistic approach that accounts for the various factors known to impact rates of firearm-related violence.
They must also do so without infringing on the constitutional rights of those who are not at risk of violent behavior.
In order to understand the relationship between mental illness, violence, and firearms, we must first understand the complex phenomenon of “mental illness.” Although many Americans will experience some degree of mental illness at least once in their lives, only a small percentage will develop serious, chronic mental illnesses that substantially impact their ability to function on a daily basis.
“Mental illness” is a complex topic that affects millions of Americans every year.
The most common interaction of mental illness and firearm-related violence is suicide, which accounts for two-thirds of all annual gun-related deaths. While the United States has a comparatively high percentage of suicides that are committed with firearms as opposed to other means, it does not have a particularly high overall suicide rate compared to countries that severely limit civilian access to firearms. It is clear that mental illness plays a key role in suicide, whether carried out with firearms or through other means, but policies seeking to reduce the overall suicide rate should account for the many factors associated with increased risks of suicide, not just the presence of mental illness. Similarly, broad limitations on firearm access for individuals who are not necessarily at a heightened risk for committing suicide are unlikely to meaningfully impact overall suicide rates and should be viewed with a heavy dose of skepticism.
Finally, while most mentally ill individuals are not—and never will become—violent, certain types of untreated, serious mental illness are associated with a higher prevalence of interpersonal violent behaviors. In particular, untreated serious mental illness is prevalent in a substantial majority of individuals who commit mass public shootings. As with suicides, this does not suggest that mass killings by individuals with serious mental illness are likely to be reduced by broadly limiting civilian access to firearms. The connection between untreated serious mental illness and specific types of firearm-related violence cannot, however, be overlooked, and must be addressed as one of many factors in a truly holistic approach to understanding the interaction between mental illness and violence.
I. What Is Mental Illness?
In order to understand the role mental illness plays in violence generally, and in firearm-related violence specifically, we must first answer one important question: What is mental illness? This is no easy task, as mental illness is an extraordinarily complex phenomenon. “Mental illness” refers to a medical condition that causes significant behavioral or psychological symptoms that impair a person’s ability to think, feel, and relate to others,1
Mental Disorders, World Health Organization (Apr. 28, 2017), http://www.who.int/mediacentre/factsheets/fs396/en/
which often causes “a diminished capacity for coping with the ordinary demands of life.”2
Our Philosophy, Nat’l Alliance on Mental Illness, http://www.namimobile.org/about-us.html
(last visited Apr. 24, 2018); see alsoMental Illness, Nat’l Inst. of Mental Health, https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
(last visited Apr. 24, 2018). The term is also occasionally used interchangeably with “psychiatric disorder” and “psychological disorder,” though these references are less common. Underlying all of these terms is the same basic reality of an individual whose mental or emotional systems are not operating in a healthy way, to the point that it negatively impacts his or her normal day-to-day functioning.
The term “mental illness” is used interchangeably with “mental disorder,” which the American Psychiatric Association defines as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.”3
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013). This definition comes from the fifth and latest edition of the Association’s Diagnostic and Statistical Manual of Mental Disorders, often referred to as DSM-5. Both the fifth edition and earlier editions of the DSM have received (sometimes appropriate) criticism for various faults, including the creation of too many diagnostic categories and labelling apparent non-conformity or political incorrectness as indicative of psychiatric illness as indicative of psychiatric illness. See, e.g., Dan J. Stein et al., What is a Mental/Psychiatric Disorder? From DSM-IV to DSM-V, 40 Psychol. Med. 1759 (2010), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101504/pdf/nihms291831.pdf;
News Analysis: Controversial Mental Health Guide DSM-5, National Health Service (Aug. 15, 2013), https://www.nhs.uk/news/mental-health/news-analysis-controversial-mental-health-guide-dsm-5/
. These criticisms, however, do not detract from the DSM-5’s position as the standard treatise on mental disorders, and the manual still provides a useful basis for understanding and analyzing afflictions long recognized as genuine mental disorders, such as schizophrenia and bipolar disorder.
Put more simply, mental illness is a medical condition that primarily affects a person’s thought processes and emotions instead of his or her physical abilities.
Just as there are many different types of physical illnesses, there are many different types of mental illnesses. It is a broad definition that can include a number of subset mental illness “groupings,” like affective disorders,4
Affective disorders, also known as mood disorders, are characterized by extended periods of depressed, euphoric, or irritable moods that cause significant interference with a person’s daily life. See Mood Disorders,
Personality disorders cover a broad swath of various maladaptive personality traits that result in significant distress, social impairment, or occupational impairment. Common personality disorders include borderline personality disorder (characterized by impulsive behavior, unstable relationships, and frequent displays of intense anger), antisocial personality disorder (characterized by consistent irresponsible or violent behaviors that disregard the rights, safety, or feelings of others without remorse), and obsessive-compulsive personality disorder (characterized by a preoccupation with details, rigid control, and orderliness that is unusually inflexible)
Anxiety disorders are the most common group of mental illnesses, and are characterized by the association of intense fear or anxiety with a certain object or situation, often involving frequent episodes of sudden, acute feelings of terror that interfere with everyday life. /syc-20350961. Diagnoses can include panic disorder—which describes sudden onsets of paralyzing terror or impending doom that cause physical symptoms mimicking a heart attack—post-traumatic stress disorder, and various phobias. Id. Some professionals characterize obsessive-compulsive disorder as an anxiety order, because for many people the repetitive actions are an attempt to alleviate distressing thoughts. See, e.g., What Is Psychiatric Disability and Mental Illness?, Boston U. Ctr. For Psychiatric Rehabilitation obsessive compulsive disorder as an anxiety disorders for these reasons), https://cpr.bu.edu/resources/reasonable-accommodations/what-is-psychiatric-disability-and-mental-illness/
and psychotic disorders.7
Psychotic disorders are those in which a person experiences delusions, hallucinations, disorganized thoughts, repetitive or nonsensical verbal patterns, or abnormal motor behavior over a prolonged period of time. See Jeffrey A. Leiberman & Michael B. First, Psychotic Disorders, 379 N. Eng. J. Med. 270 (2018).
It covers such varied diagnoses as schizophrenia,8
Schizophrenia is a serious, complex mental illness that “interferes with a person’s ability to think clearly, manage emotions, make decisions, and relate to others.” See Schizophrenia, National Alliance on Mental Illness (last visited Aug. 15, 2018), https://www.nami.org/Learn-More/Mental-Health-Conditions/Schizophrenia
. It is characterized by the persistent occurrence of at least two of the following symptoms to a degree of reduced functioning: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms like emotional disconnect or flat affect. See id.; Schizophrenia, Mayo Clinic (last updated Apr. 10, 2018), https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-20354443
Depression is classified as a mood disorder in which a person experiences constant or near-constant feelings of sadness, hopelessness, worthlessness, or anxiety for a prolonged period of time, often without knowing why these feelings are occurring. These feelings are usually significant enough to interfere with everyday activities, sleep patterns, and social relationships. It is also common for people suffering from depression to have suicidal thoughts or exhibit suicidal behaviors. See Depression (Major Depressive Disorder), Mayo Clinic (Feb. 3, 2018), https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
Bipolar Disorder is also known as “manic-depressive disorder,” and all four of its basic types are characterized by unusual but clear and intense changes in mood, energy, and activity levels. See Bipolar Disorder: Overview, Nat’l Inst. Mental Health (last visited Jan. 3, 2019), https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
post-traumatic stress disorder (PTSD),11
PTSD is a mental disorder that a person may develop after exposure to a traumatic event, often inhibiting his or her ability to mentally and emotionally cope with the event’s occurrence. Symptoms vary over time and by person, but can include flashbacks of the traumatic event, nightmares, emotional distress or numbness, irritability or angry outbursts, engaging in self-destructive behavior, and being easily startled or frightened.
Agoraphobia is an anxiety disorder in which a person experiences an actual or anticipated fear of feeling trapped, helpless, or embarrassed, which often causes them to avoid public places. See Agoraphobia, Mayo Clinic (Nov. 18, 2017), https://www.mayoclinic.org/diseases-conditions/agoraphobia/symptoms-causes/syc-20355987
As with physical illness, the symptoms of mental illness can range from mild, temporary, and manageable to severe, life-long, and debilitating.13
See David B. Kopel & Clayton E. Cramer, Reforming Mental Health Law to Protect Public Safety and Help the Mentally Ill, 58 How. L. J. 716, 719–20 (2015).
And, similar to physical illnesses, mental illness is a very common occurrence, with anywhere from one-third to one-half of Americans experiencing mental illness at some point in their lives.14
See Nathaniel S. Lehrman, The Dangers of Mental Health Screening, 11 J. of Am. Physicians & Surgeons 80 (2006) (giving a general overview of how the alleged increasing prevalence of mental illness is not truly indicative of a long-term, widespread, and growing problem, but is instead reliant on changing definitions of the problem), http://www.jpands.org/vol11no3/lehrman.pdf
Many of these individuals, however, will never present a danger to themselves or others, nor even find themselves significantly or chronically impaired.
This is an excerpt from a presentation at Hillsdale College. When I can find parts 2 and 3 I will post them. For those ofus who are psychiatrists, this simple explanation may make discussions on mental illness easier to understand.
In other words, only a small subset of individuals with mental illness will suffer from “serious mental illness,” which is generally defined as a “functional impairment which substantially interferes with or limits one or more major life activities.”16
SeeSerious Mental Illness, Nat’l Inst. Mental Health (last updated Nov. 2017), https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
While any subset of mental illness can rise to the level of “serious mental illness,” individuals with schizophrenia, bi-polar disorder, and major depression comprise the bulk of those suffering from serious mental illness.17
See What is “Serious Mental Illness” and What Is Not?, Mental Illness Policy Org (last visited Aug. 27, 2018), https://mentalillnesspolicy.org/serious-mental-illness-not/
Fewer than 1 in 25 individuals in the United States will develop one of these serious mental ill