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Sunday, November 23, 2014 / PROGRESSIVE JOURNALISM FOR POSITIVE ACTION
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Peter Barglow
NationofChange / Op-Ed
Published: Monday 7 January 2013
The important matter of gun control and safety I leave to others, except to repeat the obvious mantra, “Both people and guns kill people;” If I am enraged, crazy, and out of control I can destroy more lives with a loaded Uzi weapon, than with my Boy Scout pocket knife.

Murderers of Innocents: Common Sense Psychology and Mental Illness

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The recent Newtown, Conn. massacre has elicited much commentary about psychological causes and medical treatments that might prevent such disasters.  Some journalistic discussion is informed and pertinent, but much is mistaken and irrelevant.  I want to correct some of this and offer a few further ideas about why and how an impaired, “sick” mind produces mayhem. I will focus on predisposition including brain factors and psychiatric diagnoses, cultural reinforcement and, finally, chemical or emotional precipitators, (“triggers”). First, two questions for the reader:

1.  Why should you listen to me?  I have treated patients who have murdered innocent persons despite my best efforts and I have published many articles in many journals in psychiatry

2.  How large is the contribution of Neuroscience to our understanding of murderous rampages?  The important matter of gun control and safety I leave to others, except to repeat the obvious mantra, “both people and guns kill people:" If I am enraged, crazy and out of control I can destroy more lives with a loaded Uzi weapon than with my Boy Scout pocket knife. Neuroscience (including neuroimaging) has added zero to our understanding of the psychology of person who kill strangers and innocents.  This discipline has provided little help for psychiatric diagnosis and treatment, but its research may provide relevant understanding of violence after a few more decades. 

I. The Brain as Predictor

The National Rifle Association blames serious mental illnesses for recent frequent violent sprees.  Steinberg (NYTs, 12/2012) labeled Adam Lanza, the Connecticut shooter as a person with Schizophrenia.  The author wants to include in the same category Seung-Hui Cho, the 2007 Virginia Tech killer and JL Loughner, who shot the congresswoman, G. Giffords, among others in Arizona in 2011.  He implicates the pre-frontal cortex of the brain was vulnerable because of stress, often originating in adolescence.   If he is right, than can we in the future identify and diagnose this disease? Can we predict the danger and treat a person like those named above thereby preventing a mass catastrophe?  No, we cannot.  Localization of a major psychiatric disorder in a specific brain region is hazardous.  While excellent at detecting cancers, blood vessel abnormality or tissue loss, not even the most sophisticated brain imaging method has identified a psychiatric disorder of any kind.  The common severe injury through auto trauma or fist blows to the front of the skull (where the pre-frontal lobe is found) does not produce schizophrenia, (I. Feinberg, 1999).  Genetic aberrations do not predict violence.  J. Buckholtz (10/18/12) examined the MAOA “Warrior” gene hypothesis, identified by DNA sequencing and found it to be a science fiction fantasy.  Even the alleged association of brain cancer with violence by neuroscientists, (D. Eagleman, 8/11) is unproven.  Charles Whitman, the notorious University of Texas Tower shooter, who killed 17 persons in 1966, was found at autopsy to have a small brain tumor pressing on an amygdala nucleus in his brain. While a few experts claimed that a glioblastoma was associated with his rampage, other scientists disagreed pointing out that destruction of the amygdala produces calming in laboratory animals.

II.  Psychiatric Diagnosis as Predictor

I have argued often (Barglow 2011&2012) that here is little connection between American Psychiatric Association diagnostic entities such as PTSD with violent murderous incidents.  The categories will be officially revised later this year, but their content offers no insight into human violence.  I mention two recent examples of war atrocities many commentators attributed to PTSD. Captain Hasan Nidal’s murdered 13 innocent persons at a Texas military base in November 2009. But Nidal had not been in combat, and his behavior was more likely fueled both by a radical Muslim ideology and the threat of an assigned tour of overseas duty, than by PTSD and the aftermath of war trauma. Sergeant Robert Bales shot 16 Afghan civilians in 2012. However he was intoxicated at the time, most likely with alcoholic delirium, and had been brain damaged earlier. Forget about PTSD, schizophrenia and psychiatry are associated with violence except for some medication management.

III.  Cultural Re-Enforcement

Certainly culture can amplify violent tendencies. The violence called “Going Berserk” has an ancient history.  “Berserkers” were Norse warriors, “Baresaks,” who battled, often naked, in an uncontrollable, trance-like bestial fury, first mentioned in the late ninth century Scandinavian poem, Haraldskvaedi.  (“Baresark” may refer to a medieval thin shirt made from a bear pelt.) Today, as many Americans consider them admirable they judge them insane.  Rampage murderers are almost exclusively male. We reviewed several hundred American incidents resulting in the death of strangers and innocents during the past half a century and found only 7 were women perpetrators, (N, Kreisberg, 2012). In Israel and Switzerland, guns are as frequently owned as in the USA, but gun individual or mass murders are rare.  So culture does foster or inhibit violence as shown also by comparisons of the U.S. with France and England. North America is only a few centuries old and is still dominated by a frontier mentality, offers a tentative explanation.  But the psychological histories of America’s recent mass killers (prime example – the Columbine Colorado shooters) do show a pattern of social isolation, poverty of intimate connections, mental fragility and almost total absence of self-esteem usually associated with masculinity concerns.  If a vulnerable young man believes, “I am nothing, no-one, a powerless despised victim” then a male-superman-omnipotent rage outlet through rape of an individual woman or mass murder constitutes an ideal tragic expression.    

IV.  Final Triggers for Mass Violence

If there are symptoms of a severe mental disorder (like hallucinations that command a person to kill, or persecutory delusions) rarely do they lead to behavior ending in death by suicide or homicide?  But the inflammatory incitement by a hate group, the sudden loss of control created by drugs or alcohol or the abrupt cessation of restraining psychiatric medicine, may fuel explosive rage.   Half of the homicides in Australia from 2000 to 2006 involved alcohol consumption (Australian Institute of Criminology, 2009), a statistic mirrored by data from the U.S. and Canada. Yes, a documented record of prior violence is a valid predictor.  But the U.S. must maintain its high civil liberty standards and use preventative detention only with the highest standards of evidence. Our treatment systems, when adequately funded, can utilize benign legal methods to force persons with a clear history of violent deeds to accept life-saving medicine or at least frequent observation by family members and educated sensitive professionals. Unlike Russia in the 1960s who used mental illness as an excuse to prosecute dissidents or even benign Switzerland that keeps close track of all its citizens, America’s democracy limit our options in preventing all outbreaks of mass murder.  Even after implementing optimal interventions for those persons identified at risk for dangerous loss of control and treatment of the seriously mentally ill there can be surprises that defy inspection and prevention.

I fear that the Sandy Hook killer, Adam Lanza encapsulates this thorny challenge. A healthy young child expands its innate compassion for close family members or intimate friends and is inhibited in its intermittent normal destructive tendencies through empathically sharing the distress and pain of most human beings. Profound psychiatric disease can impair such normal progression. An autistic adolescent can, with amazing rapidity, imitate some motoric actions of a parent (using so called “mirror neurons”), but be incapable of comprehending others’ more nuanced complex emotions and precipitating unbridled rage responses.  Lanza’s mother was a survivalist who allegedly stockpiled food and semi-automatic weapons.  The boy had not spoken to his divorced father (who might have restrained him in some manner) for 2 years.  I guess that he was prescribed psychotropic medication that he used only intermittently.  In summary, this catastrophe was the final outcome of a unique and infinitely complex amalgam of variables that created terror and pain beyond human prediction or comprehension.



ABOUT Peter Barglow

Peter Barglow, MD, is a Clinical Professor of Medicine at the University of California, Davis School of Medicine.

Shamans believe when a person

Shamans believe when a person in a culture is sick it represents a sickness within that society. Jesus says in the good book, if you hate your brother you are a murderer. The outpouring of hate we have seen in the last 5 plus years, towards women, gay and lesbians, immigrants, Muslims, Middle Easterners, the poor or any citizen who receives any type of financial serves or tax break from the government, suggest HATE is the problems and we need community programs to address and decrease hate of our brothers and sisters.

One precursor to psychotic

One precursor to psychotic violent behavior that the good doctor left out was that of being a republican/rightwing. Republicans base the majority of their esteem needs upon violent supremecism. Lieing, exploiting, killing and mass murder gets their jollies off. A good bet is that Lanza's mom voted for Bush.

I don't think that the kind

I don't think that the kind of mental illness that would lead one to violence is associated with membership in any one political party, though maybe Republicans are more likely to have firearms of the sort that would permit rage to proceed to mass murder at a moments impulse. If you don't have those sorts of arms, the violent impulse is more likely to get turned inwards in harm to oneself, which doesn't often make the news the way sudden violence to others does.

I really think that it's a

I really think that it's a big omission for Dr. Barglow to have not pointed out that people with mental illness or autism spectrum disorders like Asperger's are not usually violent, and are not "dangerous" to be around. The people with severe disorders like schizophrenia, where functioning in society is impossible without treatment, that this article is about, are more likely to be victims of crime than to be violent criminals. While it's wonderful that the topic of the treatment of mental illness comes up whenever a tragedy like Sandy Hook happens, since it's ignored the rest of the time in the media, the stigmatization of the mentally ill is a counterproductive by-product that must be fought with education.

"I guess that he was

"I guess that he was prescribed psychotropic medication that he used only intermittently. " Meaning what?

One third of the American populace is on "psychotropic medication", primarily antidepressants. I do not know what, if any, medication Adam Lanza was on and so will not comment. He was, according to most of the mass media material out there, diagnosed with some form of "autism spectrum disorder". That's not schizophrenia, which the author will not even state of his own accord, but rather attribute to another: "Steinberg (NYTs, 12/2012) labeled Adam Lanza, the Connecticut shooter as a person with Schizophrenia".

The author of this piece is a professor of medicine. Perhaps he can enlighten us: how many schizophrenics go on murderous rampages? How many people with any "mental illness" do so? Provide numbers or percentages. As noted in the article, Hasan Nidal had no illness (indeed, he was a psychiatrist) apart from being a "true believer" in a murderous ideology and, as noted in the article, under a new and powerful stressor.

I'd be interested in seeing some objective writing on the number of people who take antidepressants and run amok (to use another word with a long history). In the case of some antidepressants, it may be 3%--they carry black box warnings about suicidal thoughts, but managed to keep homicidal ideation off the label. Nowhere have I seen anything on this topic.

I expected much better from a professor of medicine, unless his intended point was that monsters cannot be predicted. He has done a rather good job of pointing that out. For that at least I thank him. But I really expected better than "they may have been off their meds".

Or perhaps the problem was

Or perhaps the problem was that he was "on" his meds. Considering the laundry list of contraindications that are associated with most psychoactive medications, I would hardly be surprised that some measure of mental aberrations we are witness to are the product of, or aggravated by the drugs that were designed to ameliorate the problem. A thoroughgoing conversation about the "drug culture" we live in in this country is essential to comprehending, and with hope, alleviating the more heinous murders that have visited us. (And maybe we could expand the discussion to make sense of the "war" on drugs in the context of a medical discipline that is more a pharmaceutical distribution network than a "health care" system. Drugs are bad, except when they're not???).

And that is before we get to the idea that we live in a society that is awash in firearms, available cheaply, and infused with illusory notions of empowerment that are drummed at constantly by popular culture, and any attempt to offer a counter narrative is routinely suppressed or disparaged by the NRA.

Just like any chemical

Just like any chemical stimulant (you know some people are just not "angry" or "mean drunks"), going off psychiatric medications that are sedating can have an effect on some people of setting off a rampage of angry outbursts. If there is no access to firearms, the potential for harm is somewhat reduced.

The issue here is access to

The issue here is access to firearms. All the blathering about mental illness that follows a gun horror is just smoke to deflect attention away from the real issue which is the fetish Americans have for guns. How many dysfunctional 20-somethings are there who are filled with rage, for whatever reason, at their parents and the "system?" Lots. What differentiates them from Adam Lanza is that the others don't have access to an arsenal of highly deadly firepower with which to act out their rage. Whatever caused Lanza to act should be of no concern to anyone right now. Without the firearms, he's just another babbling soul on the street. It's the American people who killed those children. By licensing that kid's mother into arming herself to the teeth, the American people might just as well have handed those guns to that kid. As facilitators of that crime, the American people have the blood of those children on their hands. All the "shrinks" in the world won't do a thing about this so long as guns, and especially assault guns and handguns are widely available in American society.

The only part of this article I found interesting was the section on "cultural reinforcement." In my experience, "the male-superman-omnipotent rage outlet" isn't limited to "vulnerable young men." It appears to be a widely shared trait of the American male. All the hunters and gun nuts I've ever known struck me as having what I'd call a "small penis syndrome." Harboring a deep insecurity about their own masculinity, they need to kill living things, and have a "piece" with them to ward off doubts that they are "real men." We're hearing a lot these days about keeping guns away from the "mentally ill." Although I contend the DSM is a useless book of alchemy, I'd still bet the mortgage that if subjected to psychiatric testing, every gun nut and NRA member would exhibit at least one of not several indications of one or more DSM mental or personality disorders.

In this respect, we should really listen to what the gun nuts are really saying. They claim society shouldn't be concerned about them possessing guns since they are the "good guys" who only kill "appropriately;" i.e., animals and "bad guys." Of course, the gun nuts claim an ability to identify the "bad guys" and we should trust their judgment in this. Just ask George Zimmerman. What's significant here is that the gun nuts acknowledge that they are killers, albeit benign killers in their minds. They demand that the rest of us allow them to arm themselves with highly efficient and horrific tools of killing, and then trust that they possess the mental and emotional stability not to put those tools, for which they have a clear fetish, to their intended uses.

No. The only topic sane, intelligent people should be discussing right now is how to use society's collective power to disarm this society, including the gun nuts. We should regard the NRA as a threat to American society. Until this is done, more children will die, and innocent blood will continue to stain the American soul.

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