People working in all aspects of the American criminal justice system may interact with individuals who have been diagnosed with one or more mental disorders. A professional’s specific role in the criminal justice field will determine how in-depth their knowledge of mental disorders needs to be. Those in direct contact with people accessing behavioral health services, for example, may need a deeper understanding of various mental disorders that goes beyond the scope of this text. However, the following sections offer an introductory description of a number of relevant diagnoses.

2.3.1 Anxiety Disorders

Anxiety disorders are characterized by excessive and persistent fear and anxiety, and by related disturbances in behavior (APA, 2013). Although anxiety is universally experienced, anxiety disorders cause considerable distress. These disorders appear to be much more common in women than they are in men (National Comorbidity Survey, 2007).

There are a number of specific types of anxiety disorder, including generalized anxiety disorder, panic disorder, and social anxiety disorder – all of which involve different triggers and symptoms, and may have varying treatments. Specific fears or aversions – called phobias – may also fit under this category, such as disabling anxiety about being in open spaces (agoraphobia) (National Institute of Mental Health, 2023).

Anxiety disorders are the most frequently occurring class of mental disorders and often occur alongside each other and other mental disorders (Kessler, Ruscio, Shear, & Wittchen, 2009). In other words, a person may have multiple types of anxiety disorders, and/or an anxiety disorder as well as other different mental disorders. As one example, about half of all men with antisocial personality disorder (discussed in an upcoming section and closely tied to criminal behavior) also have an anxiety disorder. While it might be imagined that anxiety would reduce criminal activity, research suggests that the constant heightened sensitivity to threats, instead, contributes to criminal conduct (Hodgins et al., 2010).

2.3.2 Trauma and Stress-Related Disorders

2.3.2.1 Posttraumatic Stress Disorder

Direct or indirect exposure to a traumatic event places the people who experience this event at an increased risk for developing posttraumatic stress disorder (PTSD). Throughout much of the 20th century, this disorder was called “shell shock” or “combat fatigue” because its symptoms were observed in soldiers who had engaged in wartime combat. By the late 1970s it had become clear that women who had experienced sexual traumas (e.g., rape, domestic violence, and sexual assault) often experienced the same set of symptoms as did soldiers (Herman, 1997). The term posttraumatic stress disorder was developed given that these symptoms could happen to anyone who experienced one or more severely traumatic events.

Symptoms of PTSD (figure 2.3) include intrusive and distressing memories of the event; flashbacks (states that can last from a few seconds to several days, during which the individual relives the event and behaves as if the event were occurring at that moment); avoidance of stimuli connected to the event; persistently negative emotional states (e.g., fear, anger, guilt, and shame); feelings of detachment from others; irritability; a tendency toward outbursts; and exaggerated startle responses (jumpiness) (APA, 2013). For PTSD to be diagnosed, these symptoms must occur for at least one month.

Figure 2.3 is an artistic piece, in the shape of a brain, conveying many of the symptoms, and specific thinking or ideas, associated with PTSD.

There are higher rates of PTSD diagnoses among people exposed to mass trauma and people whose jobs involve duty-related trauma exposure (e.g., police officers, firefighters, and emergency medical personnel) (APA, 2013). These groups of people often need a great deal of support to manage symptoms of trauma; however, seeking this support has historically been highly stigmatized.

2.3.2.2 Complex Trauma

Complex trauma is based on the impact of trauma experiences that are not time limited, but that occur repeatedly. Complex trauma is a way to recognize that PTSD diagnoses are not always defined by one traumatic event; rather, someone can experience traumatic events across a lifespan. Complex trauma has not been added to the DSM as a separate diagnosis, and many people with complex trauma meet criteria for a PTSD diagnosis. However this term is used in the mental health field giving recognition to traumatic experiences that occur over and over again. Complex trauma survivors may have been held in a state of captivity, physically or emotionally, and under control of a perpetrator in the following: concentration or prisoner of war camps, prostitution brothels, long-term domestic violence situations, or long-term child physical or sexual abuse, including organized child exploitation rings (Herman, 1997).

2.3.4 Dissociative Disorders

Dissociative disorders generally involve an “involuntary escape from reality,” created when there is a disconnect between a person’s thoughts, identity, consciousness and memory. These disorders often develop as a response to trauma, where the brain seeks to control thoughts and memories. These disorders are very rare, with women more likely to have the diagnosis than men (National Alliance on Mental Illness 2023).

Dissociative identity disorder (DID) – formerly called “multiple personality” –  is one of multiple dissociative disorders that are identified in the DSM-V-TR, and it is the most well-known. People with DID exhibit two or more separate personalities or identities, each well-defined and distinct from one another. They also experience memory gaps for the time during which another identity is in charge (e.g., one might find unfamiliar items in their shopping bags or among their possessions).

DID has been a controversial diagnosis throughout the time it has been listed in the DSM. In the 1980s, rates of the disorder suddenly skyrocketed. More cases of DID were identified during the five years prior to 1986 than in the preceding two centuries (Putnam, Guroff, Silberman, Barban, & Post, 1986). This increase was almost certainly related to the popularization of DID via media, including publication of Sybil, a best-selling 1970s “true story” about a woman with 16 different personalities (Piper & Merskey, 2004).

Figure 2.5 is an image of the cover of the bestselling 1973 book “Sybil,” which led to popular fascination with – and professional over-use of – the diagnosis of what was then called multiple personality disorder.

While, upon later scrutiny, it appears that the influential story of Sybil was largely fabricated, DID is a legitimate – though exceedingly rare – diagnosis that is often tied to complex trauma, particularly a history of childhood trauma. Research by Ross et al. (1990) suggests that about 95 percent of people with DID were physically and/or sexually abused as children.

There is evidence that traumatic experiences can cause people to experience states of dissociation, suggesting that such states – including the adoption of multiple personalities – may serve as a psychologically important coping mechanism for threat and danger (Dalenberg et al., 2012). Much more common than full diagnosis of DID is this experience of temporary dissociation as a coping mechanism for people who have experienced abuse or on-going trauma. For instance, children who have been exposed to trauma or abuse in the home may have learned to dissociate (i.e. ‘space out’) during abuse to bring their mind to a space that is outside of their current physical reality. This may help them during times of abuse, however it can be counterproductive in other areas of life. For instance, a child may have a hard time concentrating in school if they dissociate during times of stress (Tull, 2023).

2.3.5 Mood Disorders

Mood disorders are characterized by severe disturbances in mood and emotions – most often depression, but also mania (Rothschild, 1999). Though all people typically experience variations in their emotional states based on many factors, a mood disorder involves fluctuations so extreme in degree and/or length of time that it impacts their ability to function.

2.3.5.1 Depressive Disorders

Depression commonly refers to intense and persistent sadness, and it can include a broad spectrum of symptoms that range in severity from mild to more serious. Depression may be linked to a variety of causes, including genetics, life circumstances, or medical events. In its various forms, it is extremely common: an estimated 21 million adults in the United States had a major depressive episode in 2020 (National Alliance on Mental Illness, 2017).

A diagnosis of Major Depressive Disorder (MDD) involves a loss of interest and pleasure in usual activities that reaches a defined severe level. An MDD diagnosis requires that a person  experience symptoms – including loss of interest in activities, appetite changes, sleep disturbance and others – for at least two weeks (National Alliance on Mental Illness, 2017). Major depressive disorder is considered episodic, with symptoms that peak and gradually abate. Although depressive episodes can last for months, most people recover within a year. However, some do not – with around 12 percent of patients showing signs of impairment associated with major depressive disorder after 5 years (Boland & Keller, 2009). In the long-term, many people with MDD who do recover will still show minor symptoms that fluctuate in their severity (Judd, 2012).

Depression, like other mental disorders, carries certain stigmas, including the misconception that people who experience it are weak, or lazy, rather than struggling with a serious mental disorder. This stigma may be particularly harmful for men, who are socialized and expected to be “strong” in the face of adversity. Watch the short video linked here at figure 2.6 to hear one man’s account of his own severe depressive disorder:

Profile: Dan L., Living with Major Depression(Figure 2.6)

Figure 2.6 is a video clip briefly describing major depression and accompanying negative misinformation, or stigma.

If you would like to read more, see this first-person account [Website] from a person who experiences depression to better understand the shame that can occur when a person internalizes the stigma associated with the disorder.

2.3.5.2 Bipolar Disorders

Bipolar disorder is diagnosed where a person has periods of depression and periods of mania. Mania is defined as a state of extreme elation and agitation. Some people who experience a period of mania may become extremely talkative, behave recklessly, or attempt to take on many tasks simultaneously. During a manic episode, individuals may feel as though they are not ill and do not need treatment. However, the reckless behaviors that often accompany these episodes can include illegal or threatening activities (APA, 2013). Bipolar disorder is considered a severe and persistent mental illness. However, people diagnosed with bipolar can often manage this disorder successfully with a combination of medication management and therapy.

A major concern in treatment of bipolar disorder is the risk for completed suicide. When someone is in the middle of a major depressive episode, they may be too depressed to take action on suicidal thoughts. However, as the person emerges from a depressive episode into a manic state, they may have the energy to follow through with suicide. If bipolar disorder is misdiagnosed and mismanaged, for example an inappropriate medication is prescribed, this risk may increase. Ongoing safety planning and suicide risk screening is essential for all mental health disorders, and these are particularly important for people diagnosed with bipolar disorder.

Stigma around bipolar disorder may arise, at least in part, from unpredictability. Bipolar is episodic and the person may not recognize recurrence of symptoms. Some people with bipolar disorder will experience a rapid-cycling subtype, which is characterized by at least four manic episodes (or some combination of at least four manic and major depressive episodes) within one year – while other people may go long periods of time between episodes when their disorder is active. This variability can make treatment decisions and adherence more difficult.

Other challenges arise from diagnosis issues. Bipolar has been over-diagnosed in the past, where clinicians failed to properly identify drug-induced symptoms that would require different treatment. At the same time, true bipolar has often been misdiagnosed (as schizophrenia or a personality disorder) or co-occurred with other mental disorders such as ADHD (attention deficit hyperactivity disorder) that, if medicated, served to worsen bipolar symptoms (National Alliance on Mental Illness, 2017). Together, these issues may contribute to a public perception that a person with bipolar disorder is necessarily very impaired, when that is not true; the stigma can then be very harmful to the diagnosed person (Mileva et al., 2013).

Watch the short video in figure 2.7 where a person diagnosed with bipolar disorder shares some perspective on his diagnosis and treatment:

Profile: Phil Y., Living with Bipolar Disorder

Figure 2.7 shares a first-person perspective on living with bipolar disorder, noting the challenges and benefits of treatment adherence.

2.3.6 Psychotic Disorders

Psychotic disorders involve changes in the ways that a person thinks and acts, to the point of seeing the world in a distorted way and losing a shared sense of reality with others. Psychosis can manifest in many different ways – including believing things that aren’t real or having strange thoughts – but regardless, the experience is very likely to be upsetting and frightening for the individual and their loved ones (National Alliance on Mental Illness, 2023).

Antipsychotic medications to treat and manage symptoms of psychosis have been available since the late 1950s. Though these medications have greatly improved over the past few decades, many people diagnosed with psychotic disorders are not relieved of all of their symptoms, and others report significant side effects from their medications. Medication adherence is critical, but people may not want to take medications that they perceive as causing additional problems. Accessibility of medications is key as well, and many people have benefitted from monthly injectable formulations, which allow a person to adhere to a medication regimen without the requirement of taking a pill every day.

Psychosis is a symptom that can appear in many different disorders, a few of which are discussed here: schizophrenia, schizoaffective disorder and delusional disorder.

2.3.6.1 Schizophrenia

Schizophrenia is a disorder characterized by major disturbances in thought, perception, emotion, and behavior. People with schizophrenia are usually diagnosed between the ages of 16 and 30, after a first episode of psychosis, or losing touch with reality. Early treatment for psychosis is associated with the best long-term outcomes, and the federal government maintains a list of providers who offer treatment for first episode psychosis [Website]. Take a look if you are interested in more information about the topic of first episode psychosis, which is often preceded by gradual changes in thinking, mood, and social functioning.

Symptoms of schizophrenia vary from person to person and may change over time. Many people with schizophrenia are able to adequately manage their symptoms in the community. For others, closer observation or hospitalization may be needed during a severe episode to ensure a person’s safety, proper nutrition, sufficient sleep, and other factors.

Hallucinations and delusions are the most common indicators identified with psychosis in schizophrenia. Delusions are false beliefs that remain unchanged, even when the person is presented with contradicting facts. Hallucinations involve seeing or hearing or smelling things that do not exist. A person experiencing hallucinations, may, for example, hear a voice making commands; commands to engage in antisocial behavior can be one path into the criminal justice system for a person experiencing this symptom.

Other symptoms of schizophrenia may include disorganized thinking and speech (such as shifting from one thought to the next without logical connection); disorganized physical behavior (socially inappropriate, excessive, or repetitive movements); and so-called “negative symptoms” such as ignoring personal hygiene or failure to display emotion (SAMHSA, 2023).

Watch the short video at figure 2.8 to hear from a woman diagnosed with and effectively managing her schizophrenia:

Profile: Victoria A., Living with Schizophrenia        

Figure 2.8 is a video sharing a first-person account of a woman who describes herself as having schizophrenia but not being defined by it, despite the enormous impact it has had on her life.

Schizoaffective Disorder

Schizoaffective disorder is diagnosed where a person meets criteria for schizophrenia as well as a mood disorder (i.e. bipolar, manic, or major depressive disorder). A person with schizoaffective disorder will have an array of symptoms – often including hallucinations, delusions, disorganized thinking, mania, and/or depressed mood. Schizoaffective disorder is relatively rare, and it can be difficult to diagnose (it is often misdiagnosed) and treat, given that it can overlap with other disorders (National Alliance on Mental Illness, 2023).

Watch this short video at figure 2.9 for a mental health professional’s description of schizoaffective disorder, as well as the concept of positive versus negative symptoms in psychotic disorders:

The Difference in Symptoms Between Schizoaffective Disorder and Schizophrenia

Figure 2.9 clarifies some symptoms of and distinctions between schizophrenia and schizoaffective disorder, both psychotic disorders.

2.3.6.2 Delusional Disorder

A delusional disorder may be diagnosed where a person has at least one delusion, or a fixed belief that is not objectively true or reality-based, that lasts at least a month. Delusional disorders are different from schizophrenia and schizoaffective disorders in that they usually first appear in mid or later life, and the delusion occurs without the other symptoms of psychotic disorders (Tamminga, 2022).

There are different types or categories of delusions described in the DSM, based on the type of belief that is involved in the delusion. A grandiose delusion, for example, would be a person’s belief that they hold special powers in society, such as the ability to read the minds of others. Another type of delusion is a persecutory delusion. This type of delusion commonly causes someone to believe others are intending to harm them. Persecutory delusions may cause anxiety, disturbed sleep and increased worry (Freeman & Garety, 2014). Someone experiencing persecutory delusions might think their thoughts are being removed (thought withdrawal) or that thoughts have been placed inside them (thought insertion). Another type of delusion is a somatic delusion, which involves a belief that something highly abnormal is happening to their own body. Somatic delusions may present as a baseless belief that there is an infestation in one’s body (e.g. an infestation of insects), as a distorted body image, or as an imagined unpleasant odor secreting from their body (BrightQuest, 2022).

Psychotherapy is most useful in treating delusional disorders, and antipsychotic medication can sometimes be helpful as well.

2.3.7 Anosognosia in Mood and Psychotic Disorders

A person experiencing anosognosia lacks insight into the fact that they have a mental illness, so they may reject their diagnosis of a mental disorder and discredit any need for medication or treatment (NAMI, n.d.). Anosognosia is not a separate diagnosis, rather it is a symptom of serious mental illness that is associated, in particular, with the psychotic and mood disorders discussed in this section. Anosognosia is extremely common in schizophrenia and bipolar disorder, likely impacting at least half or more of those diagnosed, and it is the most common reason why people with these disorders may fail to seek or continue treatment that could help manage their conditions (Treatment Advocacy Center, 2018).

In this sense, anosognosia can be an important connection between mental disorders and criminal justice involvement. Someone with anosognosia may avoid accessing treatment service or remaining consistent with their medication regimen – believing it unnecessary – which causes their symptoms to increase and, sometimes, leads them to experience legal ramifications based on their conduct or on failure to follow court-ordered treatment regimens. A person’s experience of anosognosia, and insight into their mental disorder, may fluctuate over time. It is important to understand that anosognosia is a symptom of mental illness – not a choice or willful decision to be uncooperative.

Watch the video linked in figure 2.10 if you are interested in hearing more about anosognosia from a self-advocate who has experienced this condition.

What is Anosognosia?

Figure 2.10 is a video providing a first-person account of the experience of anosognosia.

2.3.8 Introduction to Specific Mental Disorders Licenses and Attributions

“Introduction to Specific Mental Disorders” by Kendra Harding is licensed under CC BY 4.0.

Signs of Schizophrenia: Used paragraph verbatim from Living Well with Schizophrenia – What is Schizophrenia? | SAMHSA

Schizoaffective Paragraph: NAMI Fact sheet referenced: Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hal (nami.org)

Figure 2.3. Word cloud of PTSD by Phil2007 is in the Public Domain.

Figure 2.4. What is trauma? The author of “The Body Keeps the Score” explains | Bessel van der Kolk | Big Thinkby BigThink is licensed under Standard YouTube License.

Figure 2.5. Image of Sybil book is used under fair use.

Figure 2.6. Profile: Dan L., Living with Major Depressionby SAMHSA is licensed under Standard YouTube License.

Figure 2.7. Profile: Phil Y., Living with Bipolar Disorderby SAMHSA  is licensed under Standard YouTube License.

Figure 2.8. Profile: Victoria A., Living with Schizophreniaby SAMHSA  is licensed under Standard YouTube License.

Figure 2.9 The Difference in Symptoms Between Schizoaffective Disorder and Schizophreniaby BrightQuest Treatment Centers  is licensed under Standard YouTube License.

Figure 2.10 What is Anosognosia?by Living Well with Schizophrenia is licensed under Standard YouTube License.