I recently watched the film What Doesn't Kill You, starring Mark Ruffalo and Ethan Hawke . Without giving spoilers, at one point in the film both men beat up a known Pedophile. As the two characters are punching and kicking and basically using the guy's face as a speed bag they are both yelling, "You sick fuck! You sick bastard!"
I immediately had questions: if the two characters thought that the perpetrator was actually sick, why were they wailing on him? Was their labeling of him just a figure of speech and they saw his actions as simply that of a reprehensible asshole, or did they really believe he was ill?
These questions are what make mental health such a tricky animal. Conditions that tend to pull at our sympathy strings often don't get questioned . When a woman is crying all day long, loses 20 pounds from not eating and tells her friends that she is suicidal, we say that she's depressed. That's an illness and it's not often scrutinized. When a man gets fired from his job because he can't leave the house until he's counted every ceiling tile in his home and washes his hand 200 times per day, we say he has OCD. That's also an illness. And when voices that no one else can hear begin to pound in the head of a young woman, telling her that she's worthless and that aliens are probing her brain, we call her Schizophrenic. Again, an illness. Even though we can't see the actual disease the way we can when someone has the flu, most of us take the sickness at face value .
But what about those conditions that appear more nefarious? Narcissistic Personality Disorder is in the DSM-IV so does that make it an illness? What about Sociopathy? And of course sex offenders. These groups of people act in ways that, at a minimum, piss us off and, at worst, cause irreparable damage to people. When the schizophrenic woman runs out of the shrink's office because she thinks he can read her mind, we feel sorry for her because she's the only person suffering at that time. But when she drowns her children, she's suddenly the most evil person on earth, condemned to Hell. Is she not sick anymore ? Of course she is still ill, but now she's brought another person into the equation. As people, this is where when we cross that line from sympathy to anger. And this is why people like the characters in the film are praised by some. It's not as if they would have kicked the shit out of someone who had thoughts about children, it's because he took action on them, damaging a helpless child. It's the hurtful behavior that leads many to move from Illness Model to Scumbag Model. Even in prison, you can't beat up someone who is sick, but you can when he's an asshole. When he crossed that line, the characters in the film decided he wasn't sick, he was a scumbag. And while virtually all crimes have a victim, you don't often hear about a prisoner getting beaten up for murdering a 35 year-old man. That's because there isn't an overt power differential between perpetrator and victim that's seen in Pedophilia or perhaps abuse of the elderly. It's when we see such a disparity in control some of us will laud the violent behaviors of others because in a way they have leveled the playing field.
So as not to oversimplify, perceptions of illness vs. choice will vary from person to person and even by mental health pro to pro. Cultural norms, religious views, personal takes on the conscious and subconscious mind, as well as knowledge of brain structure and biochemistry, all influence how someone views psychological/psychiatric problems. You can find plenty of shrinks to say that Michael Jackson was deeply and profoundly suffering from a psychological disorder, but turn around and there are just as many who say that he made conscious behavioral choices and isn't deserving of any sort of "mentally ill" pass. Society allows us to think strange things but won't accept behaviors that damage others. So if Michael believes his mission in life is to start a Boy Scout troupe he's not going to be met with the same scrutiny as having young males sleep over his house. That's because the latter is much more suggestive of harm.
I've said this before but it bears repeating: until we have dipsticks that we can put into people's heads to give us a formal reading on how 'sick' someone is, there is going to be guesswork involved . When I worked with sex offenders and heard about the horrific things they did it was hard for me not to think that only someone truly ill would engage in those acts. When I meet a certifiable Narcissist it's hard for me to not empathize with the fact that he truly, deeply sees himself as special, independent of any evidence to support his claim. It's as if the belief is so entrenched, almost like a delusion seen in people with psychosis. But the general population is going to cut him out of their lives. This isn't necessarily a bad thing because Narcissists are generally toxic people, but most will drop him based on labeling the guy a dick rather than being ill. This, unfortunately, creates a culture of hate and anger rather than one based on what is healthy and pro-social. In other words, there are competing interests for what is best: removing the Narcissist benefits the people but not necessarily the Narcissist. Unless he says, "Wow, being a douchebag is upsetting a lot of people. I should probably stop acting that way," he is not going to change his ways. And how likely is that? Instead our action of kicking him to the curb may in fact reinforce his behavior, because we "don't get" how great he is or are simply jealous of his greatness.
So I view people who say and think and do messed up things as ill. Does that make it fact? No, of course not. Having expertise in a field doesn't mean that what you say is gospel. But I will ask you to consider the notion that just because something doesn't make you say "wow, poor guy" doesn't mean it's not pathological. A mental condition may not always pull at our heart strings, but that's doesn't mean it isn't an illness.
 I'm not reviewing the film but feel free to click here for my mind-bogglingly awesome coverage of Star Wars.
 Unless you are one of those uber-conservative types who don't see anything in the brain as an illness but simply a conscious choice. You're probably not a person who would be reading this site anyway so it is kind of a moot point.
 Dr. Gail had the flu last week and she looked like the offspring of Golom and the Crypt Keeper. Scary stuff.
 Note that this is not an argument for or against imprisonment versus psychiatric treatment or a comment on the plea of Not Guilty by Reason of Insanity. These are topics that can't be covered in entire textbooks, let alone this website.
 That data is starting to accumulate. For example, some fMRI results show differences in brain blood flow in depressed vs. non-depressed people, while PET scans show a trend of low neural activity in the frontal cortex in Schizophrenia.