Tuesday, May 31, 2022

Gun Extremism Not Mental Illness

With the most recent school shooting in Uvalde, Texas the familiar repetition persists. There is public outcry to do something.  Many commentators make the comparison to the Sandy Hook Elementary School shooting a decade ago that produced public outcry but no effective response.  In fact, since Sandy Hook there have been 266 additional incidents of school shootings. Member of the pro-gun party have already spoken out and it is clear that their position of supporting gun ownership at all costs is essentially unchanged. That includes access to military grade weapons and high capacity weapons, with minimum and in many cases no regulations.  We keep hearing about all of the polls of “responsible gun owners” who support more reasonable regulation of firearms and more reasonable firearms – but they are generally drowned out by the aggressive tactics of the gun extremism faction.

Before going any further, I will provide my assessment of gun extremism. It is based on my personal observation about how guns have essentially been radicalized over the past 50 years.  When I was in middle school in the early 1960s living in a small town in northern Wisconsin, gun ownership by adults was common.  That gun ownership was focused on hunting seasons – primarily water fowl and deer hunting.  Middle schoolers took the NRA Hunter safety course in order to be able to handle firearms and hunt. Gun safety was taught primarily with the use of lectures and pamphlets. I can still recall some of the passages in the pamphlet with captions like “alcohol and gunpowder don’t mix” and a page with suggestions about what a safe target was. There was no explanation about why a crow is a safe target. The practical side of the training was with BB guns and then a .22 caliber rifle. Even though the common deer hunting rifles at the time were larger calibers like 30.06 there was no training with those guns. There was a competition series based on accuracy and most people in the class were eventually awarded Distinguished Marksman if they practiced and submitted enough targets. Memberships in the NRA was required and for $18.00/year – you got the National Rifleman magazine sent to your home every month.  The centerfold of that magazine was an array of inexpensive rifles, often “sporterized” surplus rifles from WWII.  They typically held 5 cartridges and could be used for hunting.

But like most kids taking the course. I never went hunting or acquired any additional firearms. My family was not a family of hunters and we did not have a typical cabin in the woods where everybody gathered during hunting season. The course was taught by an instructor who had been doing it for years. His overriding message was that guns had to be taken very seriously. In fact, one of the prerequisites for taking the course was that students had to vow never to “play” at guns again. That involved never pointing a gun at a person, even accidentally on the gun range. He described a number of incidents where people were accidentally shot by relatives to emphasize that point.  We all took it very seriously and there were no close calls in the class. There was no emphasis on “gun rights”, the need for self-protection, or the Second Amendment.  Handguns were not discussed because they were not used for hunting and you had to be 21 years of age to own one.  Gun rights was not an issue in any political campaign.

I don’t want to create the impression that the firearm situation was idyllic during my childhood.  Two classmates died by firearm suicide and one was killed in a hunting accident. I knew all three of them.

That is the backdrop against which gun extremism has evolved and it contains several elements.  First of all, politics. There are obvious contradictions when politicians say it is not a time for politics in the wake of the next mass shooting after they have passed laws that allow people to avoid background checks, carry military grade weapons with high capacity magazines, allow large purchased of ammunition, carry guns without permits, carry guns openly, and not have to “stand down” in confrontations – even when their opponent is not armed. That is all politics and if you are trying to deal with the aftermath pf a shooting – you are dealing with the aftermath of that politics especially if your politics facilitated that.

At a broader political level what has to be considered is how most polls show that Americans favor “common sense” gun laws – but the gun extremists continue to have their way.  In the decade following the Sandy Hook Elementary School Shooting, nothing has been done at the federal level.  Even the most basic fix of eliminating loopholes in the background checks laws has been avoided. Even when a law has been passed in the House (HR8) that makes a few changes – to the background check law there is practically no chance that it will pass in the Senate, even though the Republicans in the Senate represent 44 million fewer people. This situation has been referred to as the tyranny of the minority or a highly motivated smaller group of people dictating in this case the laws of the nation. That tyranny is even more complicated by Republican appointed Supreme Court making decisions on both gun laws and probably abortion consistent with what the minority party wants. Demographically that comes down to white, rural, less college educated voters making the laws that in the case of guns carry out an extremist agenda.

What do I mean about gun extremism?  Basically, all of the interventions over the past two generations that have allowed lax background checks and registration, lowered minimum age to purchase handguns and high-capacity military grade weapons, the increased carrying of weapons (both concealed and open) in many cases without permits, and stand your ground laws that say there is no obligation to retreat in a confrontation – even in the case where one of the parties is unarmed. There is an associated lack of gun safety and that has clearly been a factor in accidental death of adolescents and teenagers, suicides, carrying firearms into schools, and even arming mass shooters. That lack of basic gun safety is a likely contributing factor to firearm deaths being the leading cause of death in children and adolescents (1). And finally, there is a constant stream of pro-gun rhetoric that routinely distorts those facts about gun availability and usefulness.   There is good evidence that this gun extremism began in the 1970 and 1980s and has been unabated since then. 

Since the school shooting in Uvalde, gun extremists jumped to the defense of permissive to non-existent gun laws.  They offered alternate explanations for the school shooting. Governor Abbot of Texas suggested the shooter had a “mental health challenge” since anyone who shoots someone does.  That is clearly not true.  Recent evidence from high profile media cases where a homicide occurred during a fight over a firearm are cases in point. The vast majority of homicides by firearms does not involve mental illness of any kind.  In carefully selected samples – probably biased because they are selected based on forensic criteria – only 10-25% of the sample is described as having a mental illness diagnosis (2,3).

If mental illness is not an explanation for a mass shooter or mass school shooter behavior what is more likely? Given the fact that this behavior has been going on for at least 2-3 generations at this point it likely represents a subcultural phenomenon.  Subcultures are cultural groups within a larger culture that hold beliefs at variance with the larger culture.  American culture in general is steeped in violence and crime largely through entertainment and news media outlets. There are well known violent subcultures in the United States including organized crime, gangs, domestic terrorists, and various hate groups that perpetrate violence against specific people.  These other crimes are frequently seen in the news. It is easy to ascribe some of the behaviors of these groups to individual psychopathology. You can see these efforts in many true crime television shows. Crime dramas are likely to emphasize profiling as a way that the crimes are solved. Practically all of these cases lack features that are typically seen with individual psychopathology. Instead, we hear about a profile of social factors and circumstances that are cited as motivations for the violence and aggression. Those factors are also not uniform explanations for all of the violence and aggression seen across all categories and typically are collected long after the commission of the crime and by people who seemingly have unlimited time to do that task.  A good example was a forensic psychiatrist giving a profile of the Uvalde, Texas shooter describing him as a marginalized loner who had been bullied in the past and pointing out that many shooters have this profile but only a small number of people with the profile ever engage in firearm violence.

I think it is highly likely that the mass shooter and mass school shooter have become a meme that is passed in this subculture of primarily men or boys who feel that they have been victimized and they begin to see this as acceptable payback for their perceived victimization.  It is subculturally acceptable even though it produces outrage and is completely unacceptable in the larger culture and that is why the questions about “motivation” always go unanswered. Firearms and secrecy are obviously a big part of this meme and the way it is typically enacted. Gun extremism makes it much easier to enact.  In analyzing these situations, the usual starting point is where the individual perpetrator has gone wrong.  From the perspective of an alienated subculture these people and those who identify with them consider what they are doing to be correct for various reasons and more importantly widely accepted in that subculture (7). There are many reports that these subcultures are reinforced and more accessible through social media sites where manifestos, threats, time lines, and in some cases photos and recordings of the violence are posted.

In addition to the subcultural effects, important developmental effects are seldom considered.  In the past 20 years development and brain maturation has been the object of increasing neuroscience scrutiny and in addition to structural brain changes – correlations with culture, socioeconomic class, and social network/peer environment have also been investigated. In an excellent review of this topic Foulkes and Blakemore (3) point out that averaging of large samples has been used so far to get to statistical significance – but they discuss the benefits of looking beyond the averages at the total variation of normal brain development. They illustrate significant variation in the brain volume of subcortical grey matter structures over the course of ages 7 to 23.3.  I think it is generally accepted that brain maturation by these indices is not complete until mid-20s for most people, but the graphs also suggest that there may be quite a lot of variation even at that point. Beyond that they discuss several aspects of cognition and social cognition that develop in the transition from adolescence to adulthood including reasoning, risk perception, risk taking, the varied effects of social exclusion, and the use of others’ perceptions in decision making. They demonstrate what appear to be specific cultural, socioeconomic and peer effects and discuss the neuroscience correlates where they are known.  An analysis of mass shooters at this level of detail may provide better answers in terms of prevention.

What can be done to interrupt this cycle of school and mass shooter violence? Plenty can be done.  A basic time-tested public health intervention is to remove the means for perpetrating the violence and injury. This has worked in the case of suicide prevention by specific methods as well as preventing gun violence.  In a previous post, I pointed out that Tombstone had an ordinance in 1881 forbidding the carrying of deadly weapons within the city. This was a time commonly referred to as the Wild West (1865-1895).  This period is typically idealized by movies like Gunfight at the OK Corral. That was a 30 second gunfight between three Earp brothers and Doc Holiday and 5 cowboys that occurred in 1881.  One of the precipitants of that gunfight was violation of the city ordinance about carrying deadly weapons. Contrary to most accounts – both Wyatt Earp and Doc Holliday were arrested and charged with murder.  They were released after a three-day probable cause hearing. Even during America’s Wild West days, people knew that removing deadly weapons would lead to less violence.

In many ways American streets are less protected from gun violence than they were in Tombstone in 1881.  All 50 states allow people to carry handguns.  Twenty-four states require no permit to carry a firearm.  Federal law requires a handgun holder to be 18 years of age and 21 years of age to purchase a handgun. There are currently 21 million concealed carry permit holders in the US.   There is no minimum age for possessing a rifle or a shotgun.  There was a ten-year ban on assault rifles at the federal level from 1994-2004.  The ban grandfathered in all assault weapons before 1994 and there were also many other qualifications that decreased the overall impact of the bill.  Despite these limitations the ban may have decreased the frequency of mass shootings when it was in effect. (6).  Considering that there are 258.3 million Americans over the age of 18, the manufacture and importation of firearms is brisk to say the least as well as the concentration of handguns. (Click to expand the graphic)

Concluding this post, the most clearcut path to reducing gun violence of all kinds is to improve gun regulation.  The evidence is clearly there in terms of reductions in suicides, homicides and accidental deaths. The idea that gun regulation has no effect on gun deaths or that the Second Amendment is a sacred clause that mandates gun extremism is pure misinformation.  Even as I typed this post today, the Prime Minister of Canada announced stricter handgun regulations in the interest of safety.  There is absolutely no reason that high-capacity military grade weapons are necessary in society and there are many groups of responsible gun owners who openly acknowledge that fact.

Gun extremists’ additional rhetoric about how mental illness is the real problem rather than gun access is also incorrect.  Mental illness is not defined by homicide, but by constellations of findings and associated disability. There are general developmental, socioeconomic, cultural and subcultural trends associated with violence and aggression – but none are precise enough to allow for predictions of who will likely perpetrate mass homicide.  It will take continued large longitudinal studies to examine all of these factors close enough to produce an effective population wide intervention. One of my suggestions since I started writing this blog is explicit homicide prevention.  You won’t be able to find that is a book or research paper – it is based on my experience in acute care psychiatry. In that context, I encountered many people with acute homicidal thinking who ended up on my inpatient unit.  Irrespective of any psychiatric diagnosis, we were able to help them resolve that crisis.  Before the rationed mental health system takes on another significant task, it has to be adequately funded.  And beyond the mental health system – social services are required to address many of the factors associated with violence and aggression.

George Dawson, MD, DFAPA





1:  Goldstick JE, Cunningham RM, Carter PM. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2022 May 19;386(20):1955-1956. doi: 10.1056/NEJMc2201761. Epub 2022 Apr 20. PMID: 35443104.

2:  Stone MH. Mass murder, mental illness, and men. Violence and Gender. 2015 Mar 1;2(1): 51-86.

3:  Hall RCW, Friedman SH, Sorrentino R, Lapchenko M, Marcus A, Ellis R. The myth of school shooters and psychotropic medications. Behav Sci Law. 2019 Sep;37(5):540-558. doi: 10.1002/bsl.2429. Epub 2019 Sep 12. PMID: 31513302.

4:  Firearms Commerce Report in the United States: Accessed 05.29.2022:  https://www.atf.gov/firearms/docs/report/2021-firearms-commerce-report/download

5:  Foulkes L, Blakemore SJ. Studying individual differences in human adolescent brain development. Nature Neuroscience. 2018 Mar;21(3):315-23.

6:   DiMaggio C, Avraham J, Berry C, Bukur M, Feldman J, Klein M, Shah N, Tandon M, Frangos S. Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: Analysis of open-source data. J Trauma Acute Care Surg. 2019 Jan;86(1):11-19. doi: 10.1097/TA.0000000000002060. PMID: 30188421.

7: Simon Cottee (2021) Incel (E)motives: Resentment, Shame and Revenge, Studies in Conflict & Terrorism, 44:2, 93-114, DOI: 10.1080/1057610X.2020.1822589

8: Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450. PMID: 29874513; PMCID: PMC5993413

9:  Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med. 1991 Dec 5;325(23):1615-20. doi: 10.1056/NEJM199112053252305. PMID: 1669841.

Graphics Credit:

Photo by Ed Colon, MD



  1. Your description of the Tombstone ordinance and the gunfight at the OK Corral was interesting. As I read about the Uvalde shooting, I remembered the University of Iowa shooting in 1991 when a graduate student, Gang Lu, killed 6 people including himself, wounding another who was left paralyzed below the neck, in retaliation for not being given award for his dissertation. I was a 3rd year medical student at the time at the university and remember little except being shocked at the newspaper story.

    There is a writing coach in Iowa City, Mary Allen, who has published a couple of essays in Iowa newspapers about the shooting. She was on campus at the time and in the building when she heard shots fired. One of her essays mentions an envelope found by the police in Gang Lu’s apartment. On it he had scrawled, “Cowboy justice is the only action against corporate crime.” (‘Cowboy Justice’: A first hand account of the deadly 1991 UI campus shooting, 30 years later.” Mary Allen, published in Little Village, Nov 1, 2021).

    In the other essay, she remarks on the senselessness of mass murders in the years since, and says (I hope ironically) about Gang Lu, “But at least the 1991 physics department murderer had a reason.” (“Opinion: I was present at the 1991 University of Iowa shooting. In 2022, it seems nobody is really safe.” Mary Allen, published in Des Moines Register, May 26, 2022).

    In both essays, I think there’s an implication that mental illness is an important driver in mass shootings nowadays. To be fair, she also cites the easy availability of guns. Sometimes I get tired of talking or thinking about this. I’m glad you hang in there.

    1. Thanks for this detailed comment Jim. As psychiatrists we know what to consider as mental illness. Some of my references point out that (based on the population) it may explain 1 in 4 to 1 in 10 of these incidents. The spin that this is mental illness happens immediately after these events by the same gun extremists. There is rarely any independent corroboration. The gun extremists vary in explaining the incidents as mental illness or "evil". That may date their conceptualization of mental illness. This spin also completely ignores the fact that Australia, New Zealand, and the United Kingdom all enacted guns laws after mass shooting events that prevented further carnage. That also speaks volumes to the fact that the gun extremists have it wrong and have nothing to offer in the way of solutions apart from compromise, common sense gun laws, and red flag laws.

  2. I am posting this Twitter video that illustrates in the US we can control teen access to tobacco, alcohol, gambling, and pornography but not firearms. Apologies for the Twitter link but it is the only place where I can find the video: https://twitter.com/i/status/1529910935225258001

  3. Many thanks, George. And there's a Scientific American article on the web: "The Science is Clear: Gun Control Saves Lives" https://www.scientificamerican.com/article/the-science-is-clear-gun-control-saves-lives/