Guilty by Reason of Insanity: A Psychiatrist Explores the Minds of Killers

by Dorothy Otnow Lewis

There are books—diagnostic manuals—that tell doctors how to diagnose. Some psychiatric diagnoses reflect symptoms. Take schizophrenia. To make that diagnosis, the patient tells his doctor that he hears voices, feels persecuted, believes he is controlled by outside forces. Or consider depression. To diagnose depression, doctor and patient must talk with each other at length. The patient tells his doctor he feels sad, doesn’t want to eat or have sex; he says he sleeps badly and sometimes feels the urge to kill himself. We listen carefully. These symptoms, elicited over time, add up to a diagnosis of depression. Then there are diagnoses based on signs—just signs. They reflect what the patient does, not what he thinks, feels, or experiences in his mind. Conduct disorder is such a diagnosis. To make that diagnosis, a child must manifest three or four undesirable behaviors from a list of over a dozen. Thus the child who steals, lies, runs away, or the child who fights, smokes pot, and tortures cats, has a conduct disorder. One hardly needs a diagnostic manual to come to that conclusion. One doesn’t even need to be a doctor. When