The Nashville Mass Shooting and the Confusion About Psychiatric Terminology

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

We are now about 10 days post another mass shooting that has been receiving much public attention and scrutiny. In my profession of psychiatry, these major media-covered mass shootings continue to receive attention as to the role of psychiatry, if anything, versus other etiologic factors like the ready availability of guns in the United States.

For the Nashville Covenant School mass shooting in particular—from my review of many media accounts of various political leanings—the complexity, confusion, and unusual twists and turns seem even more extensive than reliable information as details about the shooter gradually emerge. Most of what has drawn my attention has something to do with the terminology being used, which may have even wider implications.

Illness or Disorder

Most all of what I have read about the perpetrator uses the term mental “illness.” Yet, the DSM-5 uses the term “disorders,” as in our Diagnostic and Statistical Manual of Mental Disorders. The rest of medicine uses the term illness and we are licensed as a medical specialty. Why are we different? Is disorder different in implications or just a casual difference in terminology?

Emotional, Psychological, or Mental

In this case, what seems to be known about the perpetrator’s history is that there was treatment for an “emotional” condition. I have rarely heard that term used. Does it imply that the clinician was not a psychiatrist? The nature of the treatment and whether there was any suspicion of potential violence is crucial to know in a potential psychological autopsy.

Female, Male, or Nonbinary

Apparently, the perpetrator was born and labelled as “female,” but the LinkedIn account used “he/him” recently. I worked for years as a medical director in a clinic specializing in gender concerns. What is considered appropriate gender identification is in flux. For mass shootings, the statistics indicate that a non-transgender, binary female mass shooter is rare, probably at 2%, and that those identified as trans are much, much rarer. Are the normal differences along the gender spectrum an important factor? The DSM consideration of gender as some sort of disorder is in flux. Those who are identified as trans are also subject to much more social discrimination, hostility, and suicide ideation. A suicide note was left at home. Was gender then a factor in this case?

Implications for Psychiatrists

In some ways, the answers to these considerations and questions about mass shooters is relevant to who we are professionally. In our bio-psycho-social model, biologically, male gender, at least in terms of the testosterone hormone and aggressive tendencies, seems to be a factor. Psychologically, most every publicly covered mass shooter seems to have had some sort of disturbed psychiatric history, but how that is defined varies. Socially, from my experience working in a medium security male prison, for the more common mass shootings that are rarely covered in the media, gang involvement and expectations are often a major causal variable.

Paradoxically, perhaps, gun availability seems to be the major factor by far for the rate of mass shootings in the United States. I am left wondering why there are not even higher rates of such gun-related deaths, especially given our wild west historical traditions of achieving fame and fortune. To me, that strongly suggests a common involvement of some psychiatric factor.

It might help if we can be clear and more consistent about our terminology both internally and in communication with public media. If, and this is a big if, we draw a strict line with our formal classification, psychiatric illness may be a more appropriate term than mental disorder. As is often the case, what’s in a name is often quite a lot, even who we are in this case.

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times™.