Crime Writing - Insane or Inspired?

Postulated psychiatric disorders in Golden Age detectives and more recent day crime fiction protagonists

As a doctor, crime writer and Golden Age detective enthusiast, speculating on the possible psychiatric disorders of fictional characters has long been a fascination of mine. Some mental health issues are more apparent and easier to analyse than others but the reader does not have to be a trained physician to spot them. Following the personal diagnosis of bipolar disorder, I began writing a series of novels in which the central character (a general practitioner) was given the same diagnosis. My effort to gift a serious mental health disorder to a protagonist was more deliberate and blatant than most and for my part, probably a form of therapy, but it has caused me to wonder how other crime writers over the years handle this delicate topic of madness alongside genius and why it remains a popular creative tool.

When discussing patients with a potential mental health disorder, medical professionals refer to carefully researched, and regularly updated, clinical diagnostic manuals. These guidelines provide official definitions of, and criteria for, diagnosing mental health disorders. The two main diagnostic guides used today are the International Classification of Disease (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Whilst both manuals complement each other, there are some differences in the descriptions they use. The ICD is generally used in the UK and Europe and the DSM, in the USA. For the purposes of this discussion, I will refer only to the ICD.

ICD codes are alphanumeric titles given to each diagnosis accompanied by descriptions of symptoms. These classifications are developed and monitored by the World Health Organization (WHO) and are updated periodically (most recently in May 2021).

While ICD manuals help clinicians make definitive diagnoses, they do not set out an optimum treatment plan. In the UK, this job falls to the National Institute for Health and Care Excellence (NICE) who ensure the development of (by independent and unbiased committees) evidence-based recommendations. The published guidance takes the form of direction on conditions and diseases, lifestyle and well-being suggestions, demographic information and finally, pathways that ensure a high-quality standard of care and one that is provided uniformly across the country.

The likes of Marsh and Allingham steer clear of portraying mental illness in their main characters but most will recognise that Josephine Tey’s Inspector Grant, in The Singing Sands, suffers from some form of anxiety disorder. Although no medical term is given, it seems that he is recuperating from ‘overwork’ and his illness takes the form of repeated bouts of unpredictable claustrophobia. This is sensitively dealt with by Tey and the reader feels closer to him because of it when Grant reports that: ‘one moment [I am] a sane, free, self-possessed human being, and the next a helpless creature in the grip of unreason.’ Later on, he describes himself as a ‘poor nerve ridden creature at the mercy of non-existent demons.’

According to the ICD-11 for Mortality and Morbidity Statistics (version: 05/2021), Inspector Grant’s possible diagnosis might well fall under category 06 ‘mental, behavioural or neurodevelopmental disorders.’ This section is broken further into more specific ‘anxiety or fear-related disorders.’ Two diagnoses are an option: ‘generalised anxiety disorder (6B00)’ and ‘specific phobia (6B03).’

Generalised anxiety disorder is characterised by ‘marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (i.e. ‘free-floating anxiety’) or excessive worry focused on multiple everyday events,’ According to this classification, to qualify, the patient’s symptoms should also result in ‘significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.’ But the classification goes on to caveat that the symptoms must not be ‘a manifestation of another health condition and are not due to the effects of a substance or medication on the central nervous system.’

Although I am inclined to believe that generalised anxiety is the best fit in Grant’s case, it is conceivable that he may be suffering from a specific phobia in the form of claustrophobia but my feeling is that this is simply a stand-alone neurosis and one that is probably fleeting (over a matter of weeks or months). Specific phobia is characterised by a ‘marked and excessive fear or anxiety that consistently occurs upon exposure or anticipation of exposure to one or more specific objects or situations (e.g., proximity to certain animals, flying, heights, closed spaces, sight of blood or injury) that is out of proportion to actual danger.’ An important part of this definition is that the phobic objects or situations are avoided and admittedly, Grant does take the night train to evade crowds at the start of the book but it seems that in other circumstances, he is less troubled by confined spaces and the phobia, if that is what it is, does not on the whole significantly affect personal, family, social, educational, occupational, or other important areas of functioning.

As recommended by NICE, generalised anxiety disorder is initially treated by informative means, educating the patient about their illness and working with them through active monitoring to ease the symptoms. If this is of limited benefit, they may be offered individual self-help, guided self-help or help through a psychoeducational group. Following this, Cognitive Behavioural Therapy (CBT) may be offered along with drug intervention, possibly in the form of a Selective Serotonin Reuptake Inhibitor (SSRI). Benzodiazepines and antipsychotics are contraindicated in these patients.

It is difficult to know why Tey chooses to inflict this mental disorder on Grant in The Singing Sands. Many authors write what they know, correctly recognising that they are more capable of a convincing job having experienced the emotion, albeit possibly vicariously. If Tey intends to evoke empathy, I think she succeeds and from a medical point of view, the representation is perceptively handled.

Dorothy L. Sayers also uses mental illness to good effect when introducing her character Lord Peter Wimsey. Featured originally in Whose Body?, Wimsey endures flashbacks and anxiety, consistent with post-traumatic stress disorder. We see him struggling to find a grip on reality but with the support of his manservant, Bunter, a fellow war veteran from his regiment, he uses his hobby of detection to cope with the lingering effects of ‘shellshock.’

Post-traumatic stress disorder (PTSD) (6B40) is classified in the ICD-11 under ‘anxiety or fear-related disorders’ and comes below the subheading of ‘disorders specifically associated with stress.’ According to the ICD-11 classification, PTSD may develop following exposure to an ‘extremely threatening or horrific event or series of events.’ The following characteristics must be present: ‘1) re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations; 2) avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s); and 3) persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises.’

A biographical note by Wimsey’s uncle at the end of some of Sayers’ books explains that Wimsey was blown up and buried alive in a shell-hole whilst working behind enemy lines, so it is little wonder that he remains troubled still and indeed, to be meet the full criteria for diagnosis of PTSD, the patient must have symptoms persisting for ‘at least several weeks’ and these should cause significant disturbance to ‘personal, family, social, educational, occupational or other important areas of functioning.’

I think there is little question that Wimsey is living with PTSD. Under the NICE guidelines, and following a psychiatric assessment and formal diagnosis, he might be offered individual trauma-focused CBT intervention. Typically, this might be provided over 8 to 12 sessions, but more might be required if clinically indicated. Drug-based therapy, if desired, might take the form of Venlafaxine or an SSRI such as Sertraline. Antipsychotic medication may also be indicated.

Given that Sayers was twenty-one when the first world war began, it is not implausible that she may have had some personal knowledge of ‘shellshock’ victims. Whose Body? was published in 1923 and the after-effects of battlefield trauma may well have been the subject of discussion at the time. I think she deals with the topic appropriately. Wimsey’s mental suffering deepens our understanding of his relationship with Bunter and without this, we might not be so allied with them.

Conan Doyle’s Sherlock Holmes has been the subject of many appraising articles over the years and with the release of more adaptations in recent times, people’s interest in the protagonist has only grown. From the first novel, A Study in Scarlet, Holmes’ psychology has been in question. Watson refers to him as being ‘distant,’ ‘callous,’ ‘unknowable’ and ‘inexplicable,’ and these descriptions might fit with an autism spectrum disorder diagnosis.

I would say that Holmes is by far the most difficult character to assess and although he appears in 4 novels and 56 short stories, Conan Doyle’s descriptions of the man are often vague and his childhood development, not mentioned. This is disappointing as the ICD-11 classification requires that the onset of the disorder be noted as occurring ‘during the developmental period, typically in early childhood, but symptoms may not become fully manifest until later when social demands exceed limited capacities.’

There are, of course, a wide range of autism spectrum disorders and these are categorised under the heading of ‘neurodevelopmental disorders.’ Holmes, if anything, could only be identified as living with ‘autism spectrum disorder without disorder of intellectual development and with mild or no impairment of functional language (6A02.0).’ Previous scholars have suggested a verdict of Asperger’s but this, under the revised ICD-11 classification system, is no longer a term proposed as useful and although patients who have already been coded accordingly will not lose this label, the label has been withdrawn.

If we are to suggest that Holmes might live with autism spectrum disorder, according to the guidelines he must have ‘persistent deficits in the ability to initiate and to sustain reciprocal social interaction and social communication, and by a range of restricted, repetitive, and inflexible patterns of behaviour, interests or activities that are atypical or excessive for the individual’s age and sociocultural context.’ Certainly, at times socially, Holmes is abrupt and inept, often showing disregard or disinterest in others’ feelings. His excessive interest in certain activities too might be a clue to his mental health. In A Study in Scarlet, Watson reveals Holmes’ aptitudes, listing an extensive and profound knowledge in Chemistry, Anatomy and sensational literature, and yet an almost complete lack of understanding of basic astronomy, philosophy or politics. This near-obsessive, inflexible thinking might well lead to an autism diagnosis but it is impossible to be sure. No doubt readers will continue to enjoy debating the issue.

For interest, in the management of autism, NICE Guideline recommendations are based around psychosocial interventions to aid independence and fulfilment for the individual. Social interactions in the form of peer feedback groups and assistance with decision making may be offered. I suspect that being a high-functioning individual, Holmes would not attend any such interventions at all.

Conan Doyle admitted to basing his famous character on the Edinburgh surgeon Joseph Bell, although many thought that Holmes was in part, an illustration of the author himself. To write with such originality is no mean feat and autism is indeed linked to higher intelligence but we have no evidence in Conan Doyle’s life otherwise to suggest this disorder, in fact, socially, he seems to have been highly effective. Holme’s remote and insensitive behaviour might well have been the norm for physicians at this time though and certainly, their superiority would be unchallenged. Although Holmes is not a medical man, his personality could reasonably match one from when he was written. I think, on the whole, Conan Doyle was in part, writing what he knew and Holme’s exaggerated eccentricities were there simply to amuse the author (and readers).

Of course, Holmes’s possible autism spectrum diagnosis is not the only psychiatric element of interest for us in the great detective. In The Sign of Four, it is quite clear that Holmes is a psychoactive substance user but even in the first novel, this can be deduced as Watson describes his odd behaviour. ‘For days on end he would lie upon the sofa in the sitting-room, hardly uttering a word or moving a muscle from morning to night …’ He goes on to say that he suspects narcotic use and he is proved quite correct.

Holmes might now find his behaviour classified under ‘disorders due to substance use or addictive behaviours,’ particularly ‘disorder due to use of cocaine (6C45).’ Cocaine has strong dependence-inducing properties and withdrawal symptoms from it can include lethargy and low mood. If Holmes’ diagnosis of autism is still in question, the same cannot be said for his substance dependence.

In the unlikely event that Holmes should seek assistance in recovering from his cocaine habit, he might well be offered CBT. There are no drug substitutes for cocaine to ease withdrawals (unlike methadone for heroin) but symptomatic relief may be offered for problems such as sleep disorders.

The universal availability of opium, and its acceptance and usage especially among creatives at this time, might well have led Conan Doyle to write the subject into his books. His personal views on drug use were never in doubt, possibly having seen his own alcoholic father’s decline. Conan Doyle is reported to have dismissed the activity as a ‘morbid process.’ Certainly, Watson’s concern for his friend’s addiction is evident, perhaps revealing the author’s true feelings on psychoactive substances too.

Substance misuse, particularly alcohol dependence as a recognised syndrome, is a hackneyed trope employed by crime writers. Countless mildly depressed police detectives use alcohol to numb the pain of pursuing their vocation. But one particularly successful representation of alcoholism is by Simon Brett. His endearing character, Charles Paris, a roguish, philandering and wholly unsuccessful actor, introduced first in 1975 in Cast in Order of Disappearance, drunkenly staggers through nineteen novels, clearly mildly depressed and with an addiction that is quite out of control. Brett’s comedic handling of the disorder, interspersed with more poignant scenes, make the portrayal a particularly effective one, but Colin Dexter’s Morse and, more recently, Ian Rankin’s John Rebus also suffer the same ailment and both are written convincingly.

From a medical point of view, if we were to categorise alcohol dependence, this would come under the ICD-11 heading of ‘disorders due to substance use or addictive behaviours.’ The code dealing specifically with alcohol is (6C40). Alcohol has dependence-producing properties and this can result in alcohol dependence syndrome and alcohol withdrawal when alcohol use is reduced or discontinued. ICD-11 notes that not only does the misuse of alcohol medically harm the addict, but others around them also. Mentioned in the classification too are the resulting disorders associated with continued and sustained usage. Alcohol-induced psychotic disorder and alcohol-related forms of neurocognitive impairment (e.g., dementia due to use of alcohol) are declared, highlighting the fact that although an easily accessible relaxant and one often used by crime writers to define relatable characters, the author would be imprudent to glamorise the addiction.

For harmful drinkers, NICE recommends psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies). Assisted alcohol withdrawal may be offered at home or in a secure unit setting. The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam) and intensive community follow up is required following successful withdrawal.

Due to the high prevalence of alcohol addiction in today’s society, it is not unreasonable to expect some of our more recent protagonists to suffer its effects. The creation of strained protagonists who use drink to soothe is not a great stretch of the imagination and sadly, a stark reflection on our culture that many readers might well relate to.

P D James’ cerebral Adam Dalgliesh, first introduced in 1962 in Cover Her Face, is an almost polar opposite to Charles Paris in that he is an intensely private individual, enjoying solitude and poetry. We hear early on that he is a widower and it isn’t without possibility that he may be suffering from a prolonged grief reaction with emotional disconnection. In A Mind to Murder, 1963, Dalgliesh wonders: ‘How long could you stay detached … before you lost your own soul?’

Prolonged grief disorder (ICD-11 category 6B42) is a disturbance in mood, following the death of a partner, parent, child, or another person close to the bereaved. The classification stipulates that persistent and pervasive grief response is characterised by ‘longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain (e.g. sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to experience positive mood, emotional numbness, difficulty in engaging with social or other activities).’

Although it is perhaps a stretch to label Dalgliesh as such, he certainly fits some of the criteria, with disengagement and feelings of hopelessness. The ICD-11 states that this emotional state must be extensive, ‘more than 6 months at a minimum’ and should exceed ‘expected social, cultural or religious norms for the individual’s culture and context.’ Dalgliesh lost his wife thirteen years before A Mind to Murder yet still appears to be suffering. His inability to commit leads to the breakdown of his relationship with Deborah Riscoe. We only find him much later able to move on romantically when he proposes to Cambridge lecturer Emma Lavenham who he goes on to marry in the final book, The Private Patient. By this point, he is probably no longer requiring psychological assistance but if he had visited his doctor sooner, he might well have been offered bereavement counselling and possibly antidepressant therapy.

P D James’ personal life may give some clue as to her motives in writing so eloquently on mental anguish, if not, illness. Although A Mind to Murder was published one year before her husband’s death, his prolonged mental illness since returning from war may have provoked such melancholy thoughts that to expel these on paper may have seemed a form of therapeutic exorcism. James’ eloquence and verbosity in dealing with mental trauma are acute and Dalgliesh’s character, enhanced by this sensitivity.

Finally, it is impossible to write about crime fiction without the mention of Christie. Her creation of Miss Marple, an elderly interfering spinster, offers the amateur psychologist little, but her other great sleuth, Hercule Poirot, does not disappoint, with Christie writing a near-caricature of obsessive-compulsive disorder in Poirot’s thirty-three novels. We immediately get a feel for what may be in store in Captain Hastings’ first description of the famous detective in The Mysterious Affair at Styles. ‘The neatness of his attire was almost incredible; I believe a speck of dust would have caused him more pain than a bullet wound.’ This fastidiousness only seems to grow in strength with Poirot deeply perturbed by disorder, once saying that he finds it ‘really insupportable that every hen lays an egg of a different size! What symmetry can there be on the breakfast table?’

In ICD-11, ‘obsessive-compulsive disorder (6B20)’ is characterised by ‘the presence of persistent obsessions or compulsions, or most commonly both. Obsessions are repetitive and persistent thoughts, images, or impulses/urges are intrusive, unwanted, and are commonly associated with anxiety.’ A compulsion occurs when an individual feels forced to ignore or suppress or neutralize obsessions. ICD-11 qualifies this by explaining that ‘Compulsions are repetitive behaviours including repetitive mental acts that the individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of ‘completeness’. The one element that does not fulfil the criteria for this diagnosis in Poirot’s case is the final explanation of the disorder. ICD-11 states that ‘In order for obsessive-compulsive disorder to be diagnosed, obsessions and compulsions must be time-consuming (e.g. taking more than an hour per day) or result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.’ I see little evidence of this in Poirot’s case. He does not appear to spend hours on his routine and his ritualistic perfection seems only to offer the character enjoyment.

Currently, people diagnosed with obsessive-compulsive disorder will be offered CBT and if desired, SSRI drug therapy, but these are prescribed with caution.

Poirot is undoubtedly one of crime fiction’s most enduring characters. His perfectionism might be attributed to his creator’s lack in this department, with her described as having no method to her writing and ability to do so only when struck by inspiration. Admittedly, if Christie is genuinely depicting OCD, the comedic element falls rather flat for those who really suffer the illness. But I think few could be grossly offended by her rather ridiculous creation who, for his own part, sets himself up more often than not, defusing many a heavy situation with humour.

Dark humour and evoking empathy are useful writing tools in bringing the reader closer to one’s characters. Authors write mental illness into their books for a variety of reasons probably, some having experienced it first-hand themselves and others, simply reflecting on society. Certainly, in making the detective flawed, many succeed in reaching out to their audience. Faultless individuals are quite unlikeable and although a reader may want to be as intelligent, methodical or witty as the protagonist, it is dangerous on the crime writer’s part to deny their audience at least half a chance. By impeding the protagonist with some failing, this problem is overcome. Some care should be taken in introducing mental illness into a regular character though and it would be foolish to do so without extensive knowledge or experience of the subject. Undoubtedly, creating an unreliable narrator due to psychiatric disorder might well be seen as at best, insensitive and, without a deep understanding, quite inaccurate, with nuances of the illness missed and other symptoms, wildly caricatured.

Quite apart from clever plotting by blending themes of greed, neglect, love, obsession, morality and deceit, an author of crime fiction has many opportunities to make a powerful impression on their audience. Add in a few elegantly crafted psychological defects and, if done well, in my opinion, we break taboos and destigmatize mental health disorders. If our fictional heroes live with psychiatric issues, so too can we, and perhaps also, go on to do truly great things like them.

(Published in Crime and Detective Stories, August 2022)