How do real psychiatric hospitals approach the so-called "criminally insane?" Who are these mentally ill criminals? And importantly, what does mental illness have to do with violence? In Batman: Arkham Asylum, the player takes on the role of the iconic comic-book hero, trapped in a psychiatric hospital with mentally ill criminals. Now, this is a fictional universe in a creepy, spooky setting and nobody expects Arkham's portrayal of modern medicine to be particularly realistic, but it does bring up the above questions.In Arkham Asylum, the player finds various character bios indicating their respective psychological attributes. According to these, some characters appear to suffer from severe mental disorders. For example, the Joker is described as a ''homicidal maniac,'' Harley Quinn as a ''homicidal psychotic,'' and Hugo Strange as a ''psychological analyst with schizophrenic episodes." Other villains have less flamboyant descriptions suggesting more minor mental disorders (or no mental disorder at all!). For example, the Penguin is described as a ''criminal driven by a need to prove himself'' and Hush as a ''sociopath." Let's not think too much about whether these descriptors are accurate or realistic… this is a cartoon universe, after all. However, the game does leave an impression that some patients are severely ill while others are simply cruel but not mentally ill per se. From these descriptions, it’s hard to understand why some villains, super or otherwise, end up in a psychiatric hospital and some end up in a prison. So, in real life, which criminals end up in a place like Arkham? The short answer is, none of them. Thankfully, we don’t have places like Arkham in real life. That said, here’s the longer answer. As the old joke goes, there are two kinds of people in the world: those who seem to be responsible for what they do, and those who don’t. In the first group, you have individuals with no mental disorder–you don’t have to be unstable to be a criminal–and those who do meet criteria for a mental disorder that doesn't excuse them from their crime. It's in this first group that we often find ''psychopaths'' or ''sociopaths,'' both of which are labels that don’t actually appear in the widely used "Diagnostic and Statistical Manual of Mental Disorders" from which most American mental health professionals draw their diagnoses. The more academically-acceptable diagnosis for most of these individuals would be "antisocial personality disorder" (or, ASPD). Don’t confuse this with someone who gets anxious in social situations, though. In the second group, we often have patients going through "psychosis." So, let's figure out the difference between psychosis and psychopathy, two similar-looking words with entirely different meanings. Psychotic and Not Criminally Responsible Psychosis generally refers to people who, for one reason or another, are experiencing disordered thoughts or have trouble telling what’s real from what isn’t (we call this impaired reality testing). It's generally characterized by the presence of delusions (unwavering false beliefs, not explained by the person’s cultural background, which persist in spite of contradictory evidence), hallucinations (often hearing voices that no one else can hear) and disorganized or strange behaviors. This means that they can commit crimes without understanding or appreciating that what they did was illegal or immoral. They can commit crimes without understanding or appreciating that what they did was illegal or immoral. It's unclear if there is a truly psychotic character in Arkham Asylum; a character like Harley Quinn might fit in this group, and the case could be made for Batman himself (although he's much more likely to walk out of an interview with a diagnosis of something like post-traumatic stress disorder with obsessive-compulsive personality traits). For example, Harley Quinn might hold the delusional belief that Batman is evil or that the Joker loves her, despite clear evidence to the contrary. In real life, a person may believe his neighbor is the Devil, and he may hear the voice of God commanding him to defend himself. In this respect, a psychotic patient committing a crime is often found "not criminally responsible" on the grounds that they acted based on false beliefs and misperceptions. Psychopathic and Criminally Responsible In contrast, psychopathy or ASPD have nothing to do with impaired reality testing. ASPD is more or less synonymous with the non-medical term, "sociopath," and psychopaths are a severe subgroup of individuals with ASPD. Psychopaths are short-tempered individuals who are deceitful and manipulative, who ignore and violate social rules. People with ASPD tend to be selfish, impulsive, and sorely lacking in empathy and guilt, and while many are perfectly functional, some are capable of truly horrifying acts. Oswald Cobblepot, the Penguin, would fit well in that group; he’s a man who’s intelligent, rational, utterly self-absorbed, and totally indifferent to whether anybody else needs to be hurt to get what he wants. Most high-profile villains in the DC Universe come across as being more psychopathic than psychotic. The Joker doesn't hear voices, he doesn't believe he has a special purpose, and he doesn't feel that the people he's hurting somehow deserve it... he just thinks it's funny. The Joker, as portrayed in the Arkham series, actually appears more psychopathic than psychotic. He doesn't hear voices, he doesn't believe he has a special purpose, and he doesn't feel that the people he's hurting somehow deserve it... he just thinks it's funny. The Joker may commit crimes for reasons that don’t make sense to the rest of us, but he knows full well that the things he does are seen as "wrong" by society. This means that by most definitions, he’s criminally responsible. There is raging disagreement amongst mental health professionals as to whether psychopathy (or for that matter, other "personality disorders"), is considered a "real" mental disorder. In any case, psychopaths are generally fully able to understand and appreciate their criminal acts and are often found guilty for their crimes. Interestingly, both psychopaths and psychotic offenders end up in Arkham's asylum. That is not unheard of, as both antisocial and psychotic patients are often juggled between the criminal and mental health systems. It's unclear how Arkham psychiatrists hope to "treat" villains like Croc, but the player does find audio logs suggesting medication and psychotherapy trials. For example, Dr. Whistler comments on Zsasz not responding to medications, and Dr. Young has the Riddler talk about his childhood. Sadly for Dr. Whistler and Dr. Young, psychopathy is difficult to "treat." No amount of medication or psychotherapy will ever change the Joker into an empathic, peaceful individual. For that matter, I would personally keep a 5-foot-thick bulletproof glass wall between me and the Joker before I ever consider a psychotherapy! Fortunately, psychotic individuals can (often) be treated and reintegrated in society. The Insane Versus The Dangerous Unfortunately for Batman, Arkham patients are rather dangerous and violent, which brings us to the last question: are mentally ill patients violent? Actually, this is too broad of a question, as "mentally ill" technically includes personality disorders such as psychopathy as well as substance use disorders (like drug abuse), which can lead to increased risk of violence. Let's focus on psychotic patients then, and the most common disorder with psychosis, schizophrenia. The short answer is NO, schizophrenia does not lead to increased violence per se. In reality, patients with schizophrenia are much more likely to be victims than they are aggressors. Patients with schizophrenia who also abuse substances (alcohol, amphetamines or others) appear to be more violent, but the vast majority of people with schizophrenia are not violent and are not criminals. While Batman: Arkham Asylum does not aspire to be an accurate depiction of forensic psychiatry, it does illustrate interesting points about psychiatry and criminology. With Batman: Arkham Origins due out later this year, we’re soon going to be treated to another parade of psychopaths, and our experience of the game will only be richer with a better understanding of who’s insane… and who’s just dangerous. Eric and Carl are psychiatry residents at McGill University and science media consultants for Thwacke. For more, like us on Facebook and follow us on Twitter.