The NYTimes Editorial On Why Mental Health Can't Stop Mass Shooters -What's Wrong With It?

There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018.  It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis.  Since it popped up it is being posted to Twitter by more and more psychiatrists.  It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior.  Dr. Barnhorst gives examples of people who allegedly make threats and then deny them.  She discusses the legal standard for commitment and its subjective interpretation.  For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side.  That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted.  If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released.  That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.

If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them.  Unless his legal status changes they may give him the guns back.  In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back.  I am not aware of any psychiatrist who has done that.  The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done).  That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial."   Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled.  Unfortunately not all states participate in this check system and there are numerous exceptions if they do.

I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms.  At the political level there is no nuance.  At this level the degree of distortion is the greatest.  The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not.  The legal arguments are slightly more informed, but still fairly crude.  Like most legal arguments they threaten or reassure.  For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities.  On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires.  The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.

At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression.  It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing.  They are successful at stopping violence acutely and on a long term basis.  Given the legal biases they cannot do it alone.  There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system. 

Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:

"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence." 

She cites "angry young men who harbor violent fantasies" as basically being incurable.  The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one.  The facts are seldom considered.  There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates.  The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology.  There are for example school shooter databases that record events as anytime a firearm is discharged in a school.  That results in a very large number of weapon discharges but most where nobody is injured.  There are databases that just list events but there is no analysis of whether mental illness was a factor or not.  In mass shootings in half the cases the shooter is killed or suicides.  Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available.  The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.

The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1).  The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses.  I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.

He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill.  His definition of mentally ill as essentially being psychotic.  He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic.  Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment.  Using this conservative methodology - it is apparent that mental illness in this population is not rare at all.  What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.

My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:

1.  Increase the purchase age to 21 years.  Eliminate access to military style weapons.

2.  All purchases must be cleared through the NICS system.  All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.

3.  The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria.  In other words, you are eliminated from gun purchases if you have been reported for these problems.  That may sound a bit stringent but I think there is precedent.  You cannot make threats about air travel at an airport.  If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
 the are special instructions on what it takes to keep firearms from you.  I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).

4.  At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.

5.  Uniform protocols need to be in place for terroristic threat assessment.  It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention.  The person making the threat should be removed from that environment and contained pending further investigation.

6.  On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start.  Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence.  There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.

7.  On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems.  Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings.  In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff.  They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings.  Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.

8.  In the early years of this blog - I was an advocate for violence prevention and I still am.  Violence and aggression have the most stigmatizing effects of any mental health symptoms.  I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients.  It needs to be seen as a public health problem and education and prevention are a first step.

Those are my ideas this morning.  I may add more to this page later.  If you have a real interest in this topic Dr. Stone's paper is a compelling read.  If I find others of similar quality I will post them here.  Don't hesitate to send me a reference if you have one.

The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter.  And yet there is a clear overepresentation of mental illness in this population.  Some level of cooperation as suggested above will result in a much tighter system for addressing this issue.  We do it in airports and in domestic violence situations.  We can also apply more uniform and stringent expectations to schools.


George Dawson, MD, DFAPA


References:

1:  Amy Barnhorst.  The Mental Health System Can't Stop Mass Shooters.  New York Times February 20, 2018.  Full Text Link

2:  Stone MH.  Mass Murder, Mental Illness, and Men.   Violence and Gender. Mar 2015: 51-86. Free Full Text Link



Graphics Credit:

Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.

Layered arguments graphic was done by me in Visio.

 

Mass Shootings in America - Why They Are not Terrorism

You will find more statistics at Statista

American media is so used to mass shootings that many are set up to reflexively release provocative and often poorly thought out theories after the incident.  The fact that there is rarely much more information about the shooter's motive reinforces this process.  The tragic event in Las Vegas is no exception.  It is currently the worst mass shooting incident in the USA and here is a link to the previous two.  There is the usual gun debate and public relations maneuvers by wide gun access advocates.  There are the rational responses by citizens calling for some measure of gun control.  I say rational because there is excellent evidence (1) that stricter gun laws enacted after a mass shooting incident, prevent further mass shooting incidents.  In the media coverage after this incident and on various social media cites there appears to be some confusion over whether American mass shooters are terrorists or not.

Before I go on, I have noticed that in social media many people are posting state statutes that equate terrorism with acts of violence.  The US Code defines both international and domestic terrorism as intimidation or coercion on a domestic population in order to influence the conduct or policy of the government.  I would take it a step further in that there needs to be an ideological message.  All of the news about who takes "credit" for these incidents implies this is a critical dynamic along with all of the publicity generated by many of these groups with very explicit messages.

For all of these reasons, typical mass shooters in the United States are not terrorists.  There is no ideology, no message, and no attempt to influence the government.  There certainly may be mental illness, but that alone is insufficient to produce a typical mass shooter.  There are many more mass shooters that are not technically mentally ill than those who are, but I will admit that the methodology for studying the problem is inadequate since many of these perpetrators are dead or unwilling/unable to produce a coherent story.  I will also be the first to admit that this is my impression, because the data on mass shooters is large and I have no access to all of that data.  For example, the NY Times came out with a graphic showing that in the past 477  days in the US there were 521 mass shootings (2).  They use the criteria of 4 or more people killed or injured qualifying as a mass shooting.  I have no access to that data.  There have been attempts to look at the data according to specific types of mass shooters like rampage killings.  The most recent FBI study looked at where the events occurred, if there was any connection between the shooter and the location.  It did not focus on the potential motivations of the shooters despite having access to all of the data:

Though this study did not focus on the motivation of the shooters, the study did identify some shooter characteristics. In all but 2 of the incidents, the shooter chose to act alone. Only 6 female shooters were identified. Shooter ages as a whole showed no pattern. However, some patterns were seen in incident sub-groups. For example, 12 of 14 shooters in high school shootings were students at the schools, and 5 of the 6 shooters at middle schools were students at the schools. (p. 20).
  
It did look at some specific locations and the relationship of the shooter (employee, family member)  to that location.  The critical analysis of this report was that it appeared that although mass shootings have occurred a long time in the United States - they appeared to be increasing in rate and lethality as indicated by the following graphic from that report:

The graphic points out that not only is the general problem of mass shooting being ignored from  policy perspective, the increasing rate and lethality of these incidents is being ignored.  From the FBI report some of the motivations clearly involve enraged employees or former employees.  Mental illness was omitted as a possible motivation.  All of the vignettes of each incident are attached to the end of the report.

My views on mass shootings, violence prevention, and even homicide prevention have not changed from my previous posts in this area.  I will add one more dimension to the issue and that is the cultural meme of the mass shooter in America.  Granted there are various etiologies that can produce a mass shooter, but after terrorism has been  eliminated there is a prominent cultural meme present in the USA and that is - if I feel like I have been wronged - I can pick up a gun and and make things right (at least in my own mind).  Americans are oblivious  to the presence of this thought pattern in our culture and what it implies.  The most significant implication is that reality is suspended if I merely feel like I have been wronged.  The reality of why I was fired, divorced, arrested is secondary to my thoughts on the matter.  Most adults in this country have had experience dealing with somebody who had this pattern of thinking.  To some extent most people with some level of self awareness can catch themselves in the process of making the same errors - most frequently when angry or emotionally upset.  Varying degrees of road rage is a classic example.  There is an anthropological argument that violence, aggression, and homicide are age old solutions to often minor disagreements.  In many cases the aggression spreads to a  larger number of targets than were involved in the original conflict.

There is the issue of violent and homicidal fantasy being common in both normative and violent criminal populations (4).  Various theories about the function of these homicidal fantasies exist.  Some homicidal fantasies seem higher risk than others but the study of fantasy per se, is limited by inadequate methodology including degree of self disclosure and lack of long term follow up.  Much of the work is anecdotal.
   
At the cultural level is there a larger problem in America?  American culture unquestionably has viewed firearms as tools for settling disputes.  That plays out time and time again in various movies and to varying degrees in American subcultures where being capable of violence and aggression is synonymous with being respected. To be very clear most people can tell the difference, but cultural influences can have a powerful effect.

No matter what the intrapsychic or cultural ground for gun violence, one thing is obvious if a firearm is available it is more likely to be used in both incidents of suicide and homicide.  We currently have a Congress and various political factions that are in denial of that basic fact.  Unless there is a radical change in that political approach and/or a concerted effort toward violence and homicide prevention reversing the trend in the FBI graph is unlikely.


George Dawson, MD, DFAPA




References: 

1:  Chapman S, Alpers P, Agho K, Jones M. Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev. 2015 Oct;21(5):355-62. doi: 10.1136/ip.2006.013714rep. PubMed PMID: 26396147.

2:  The Editorial Board.  477 Days. 521 Mass Shootings. Zero Action From Congress. New York Times; October 2, 2017.

3:   Blair, J. Pete, and Schweit, Katherine W. (2014). A Study of Active Shooter Incidents, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. 2014.

4: Gellerman DM, Suddath R. Violent fantasy, dangerousness, and the duty to warn and protect. J Am Acad Psychiatry Law. 2005;33(4):484-95. PubMed PMID: 16394225

Is President Obama Reading This Blog?

Not really, but you can find the mass shooting links on this blog at this link.  They extend back three years and they overlap with a number of posts on homicide prevention.  They also overlap in many areas with the President's speech.  This was President Obama's 15th address to the nation following a mass shooting incident.  A couple of other landmarks - this was the 40th time this year that a gunman opened fire in a school and the 294th mass shooting incident this year.  Both of these markers illustrate how tragic but absurd this problem is in America.  How can responsible people allow this to happen?

The President is coming to the only logical conclusion that a person can come to about mass shootings and the relationship to firearms.  That point in this speech was when he said that our thoughts and prayers for the families and survivors are not enough.  We cannot keep making these pat statements in response to continuous mass shootings as though nothing can be done to prevent them.  We cannot treat mass shootings like they are routine:

"Earlier this year, I answered a question in an interview by saying, “The United States of America is the one advanced nation on Earth in which we do not have sufficient common-sense gun-safety laws -- even in the face of repeated mass killings.”  And later that day, there was a mass shooting at a movie theater in Lafayette, Louisiana.  That day!  Somehow this has become routine.  The reporting is routine.  My response here at this podium ends up being routine.  The conversation in the aftermath of it.  We've become numb to this."

 The familiar refrain about condolences to everyone and now it is time to move on needs to stop.  With governments that regulate what a lot of us do at work every day - right down to how we cross the Ts and dot the Is - it is difficult to believe that more functional gun control laws cannot be passed.  In his speech he points out that this is possible and there are laws that have been shown to work in other countries and in specific counties and municipalities in the United States.

At one point he speaks to the mind of the perpetrator:

"We don't yet know why this individual did what he did. And it's fair to say that anybody who does this has a sickness in their minds, regardless of what they think their motivations may be. But we are not the only country on Earth that has people with mental illnesses or want to do harm to other people. We are the only advanced country on Earth that sees these kinds of mass shootings every few months."

People tend to get hung up on whether specific perpetrators have a diagnosable mental illness and whether it is treatable.  They tend to get hung up on whether the behavior of violent individuals can be predicted over time.  They tend to be very pessimistic about the nature of the problem and whether insightless people will ever be able to get the kind of help that they need to prevent mass shootings.  It might be easier if there was some education about the types of situations that lead to these problems and the fact that in most of those cases, help is available.  That specific help will prevent homicides and prevent the unnecessary loss of lives of both the perpetrators and the victims.  

The President ended with a comment on the political process and an appeal to gun owners on the issue of whether they are being supported on this issue by an unnamed organization or not.  It was a compelling speech and the arguments are powerful.  As a politician, he is focused on political action and on common sense gun safety laws.  I have stated that it might be best to proceed from a public health standpoint and a focus on violence prevention and forget about legal approaches largely because there has been no political will on this issue.  President Obama has given one of the most compelling speeches on this issue that I have ever witnessed and it will be interesting to see the result.

From the medical and psychiatric side, our advocacy still needs to be on the public health side of the equation.  For me that comes down to seeing the problem to a significant extent as violence and homicide prevention.  We need more public education on the predisposing mental states and how to get assistance when these states are recognized.




George Dawson, MD, DFAPA


References:

Statement by the President on the Shootings at Umpqua Community College, Roseburg, Oregon.  October 1, 2015.  Transcript

Billboard - Stigma or Not?

I don't know how I missed the controversy but the APA has vigorously criticized a billboard that sends a message about inadequate access to mental health services and inadequate gun control.  I found out about it only through the APA listserv yesterday.  The Psychiatric News alert can be viewed here.  The billboard can be seen on major news services like NBC here.   If anyone can spare a photo of this billboard please e-mail to me and I will post it in the body of this essay.  The message basically states "Over 40 million Americans with mental illness - some can access care - all can access guns."  It is signed by Kenneth Cole.  He has a history of activist billboards and Twitter posts and is no stranger to controversy.  He has also discussed raising his brand's profile through the social responsibility messages.  In this case some APA members were outraged at what they perceived to be a stigmatizing message.

My perspective is that the message on the billboard is accurate. There is nothing to be gained by suggesting that Mr. Cole is trying to state that most people with mental illness are dangerous.  But there is the issue of whether a professional organization should be commenting on what they perceive as a controversial billboard in the first place, especially when it may be used to promote a brand name.  In this era of social media and the current trend for public shaming, I would suggest that scoring points in that landscape is the last thing any professional organization should be doing.

The fact is that most acute care psychiatrists are making these kinds of assessments every day in the United States and multiple times a day.  The vast majority of people designated to have a mental illness on this billboard do not need to see psychiatrists.  Acknowledging the fact that psychiatrists are actively engaged in violence prevention and that a small but significant number of people with mental illness are violent and aggressive and that it is a treatable problem is a very important message.  The potential benefits include:

1. Less stigma for people who are violent and aggressive as a result of severe mental illness.  The current bias is to see this behavior was willful and punish them based on a moralistic approach to mental illness.  That is until the violent and aggressive person is a family member trying to harm other family members.  At that point, there is no myth of mental illness and all of the talk about how the mentally ill are not aggressive is meaningless.

2. Clearly define the problem and develop centers of excellence for treating this problem.  In every metro area in the U.S. there are a handful of acute care psychiatric units and even fewer who accept violent and aggressive patients.  All of the violent and aggressive patients are typically brought to one or two hospitals that are set up to address the problem.  Those hospitals have protocols in place to treat the problem and many of them do a lot of civil commitments.  There is no funding source that is adequate to provide the level of treatment for these patients who must be hospitalized until they are no longer dangerous.  They also require more intensive staffing patterns by staff who must have a much higher level of training than in less intensive situations.

3. A denial of the potential for violence and aggression is inconsistent with the recently released Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition.  That document has explicit commentary about the psychiatrist’s role in addressing aggression.  There are 41 references to aggression in the body of the paper including 13 bullet points on the Assessment of Risk For Aggressive Behavior (p 23).  There are thirteen references to firearms.

In my opinion, the assessment of violence and aggression that is typically done in crisis situations by psychiatrists is more extensive than what is captured in the guideline. As an example there is no discussion of transference or countertransference issues and how they affect the treatment team and their approach to the safe treatment of violent and aggressive patients.

4. A more clearly defined role among advocacy organizations is a better role for professionals. The political use of the term “stigma” is at times all encompassing and it obscures the real source of the problem. For example, stigma is not the reason why there are no services available for psychiatric care.  Managed care companies and the governments that subsidize them and sanctify their business tactics are the reason there are no services.  The APA has been talking about stigma for years and it has done absolutely nothing to increase services or stop the rationing.  The highly acclaimed parity legislation initiated by Senators Paul Wellstone and Pete Domenici has done nothing to break the chokehold on mental health by businesses and governments.  There is new legislation in the works to “enhance” the original parity legislation because it has no teeth and has not made a difference. Businesses do what they want with the blessing of state and federal governments.

5. In some cases advocacy organizations are at odds with clinical psychiatrists who are treating patients with severe mental illness and aggression.  One of the positions taken by at least one of these organizations is that psychiatrists could be easily replaced by “prescribers” in state hospitals where aggressive patients are sent.  The government in that case took the position that an administrator with no clinical experience could come into a state hospital setting and develop a program to treat patients with mental illness and violence and aggression.  That plan failed.

These are a few of the problems associated with denying the correlation between severe mental illness and violence and aggression in a subset of patients with severe mental illness. The reality is that there are thousands of psychiatrists that face these problems every day. Their goal is to keep people safe and prevent violence. Acknowledging what they do on a daily basis, supporting that work and the importance of that work to patients, families and the community is a step in the right direction.

Suggesting that it is too stigmatizing to discuss that issue is not a step in the right direction.




George Dawson, MD, DFAPA



Supplementary 1:    I contacted Kenneth Cole (the company) through the web site and asked them to send me an image of their billboard for use in this post.  I included a link to the post so the specifics could be read as well as the entire blog.  I was advised that although they appreciate my interest, the image was proprietary and therefore they could not send it to me.  I don't know if they are claiming that about every image or just the one I wanted them to send me.  It made me wonder if they are aware of how widespread the image is used on the Internet.

Supplementary 2:   I was graciously sent a photo of this billboard by a resident New Yorker.  I contacted Kenneth Cole again and was told again that I could not even use an independent photograph of their billboard for this post.  I really doubt that any place else displaying these billboard photos has gotten permission from them, but I am just a guy writing a blog and can't afford to get into it with them.  So there you have it.  Go to any one of the other hundreds of places on the Internet that have posted this picture to view it.

    

Why Would A Psychiatrist Carry A Gun?

I thought I could resist commenting on this issue, but after seeing what the press did with this issue today - somebody needs to set things right.  What may be going through a psychiatrist's mind as they think about arming themselves?  I don't need to speculate about another psychiatrist.  As I recently posted, I have had to make the decision and in talking it over with colleagues many of them had to make similar decisions.  It is definitely not a linear process.  Here are some of the elements:

1.  Contact with aggressive and violent patients who have severe mental illnesses:  In another recent post - the most familiar scenario is the person with paranoia or a severe personality disorder and who uses the psychological defense of  projection or projective identification.  In the popular vernacular a person who tends to blame other people for their problems, even when there is no realistic connection.  That can happen to psychiatrists because of the unique a aspects of the relationship and nature of treatment, but it can also happen to other physicians, therapists, and counselors.   In many  cases the blame is projected onto anyone who works for the organization or clinic and that puts everyone in danger - including the clerical staff.

2.  A significant substance use disorder:  The usual scenario is the severe psychiatric disorder, aggressive behavior and a substance use problem.  Most intoxicants are disinhibiting and they have the potential for activation, increased paranoia, and increased psychosis with impaired judgment.  They can also lead to aggressive or suicidal behavior that occurs during blackouts.  That not only increases the likelihood of action on a threat but makes any contact with patients in this context very problematic.  That includes crisis intervention centers, emergency departments,  acute inpatient psychiatric facilities, and detox facilities.  It is crucial that all of these settings have adequate staffing and crisis plans to contain both any  aggression that occurs and ways to limit access to people with weapons or people who are out of control.  In some cases patients with acute intoxication need to be rapidly sedated to prevent self injury or injury to staff.

3.  A specific threat against self or family:  Any threat needs to be taken seriously and this is also a training point.  Every mental health professional needs to learn how to address this issue and the first step is to make sure that everyone in the workplace is aware of the threat.  A threat assessment needs to be done and matched with the appropriate plan.  Those plans could range from an immediate call to the police, emergency hospitalization,  civil commitment, and interventions about how the clinic or hospital will interact with that person in the future.

4.  Police involvement:  This is not a debate about gun rights.  Nobody tells you in medical school that homicidal patients are an occupational hazard.  Nobody tells you that if somebody threatens to kill you - you may be on your own.  When you hear about some of these scenarios on television and in the movies one of the themes typically is:  "Well these are just threats.  He/she hasn't actually done anything yet so we can't do anything."  That was a very common attitude from law enforcement 20 years ago.  

Attitude problems can also exist at the court level.  I have testified in hearing about threats where it was suggested that this was an occupational hazard for psychiatrists and therefore less relevant as evidence of criteria for commitment.  Nursing staff are also subjected to these illogical attitudes.  Assaults on nurses are commonly viewed as an occupational hazard and the administrative response is generally that the responsible patient is never prosecuted.  In this era where civil commitment is often watered down to the point that it is completely ineffective, court ordered treatment from a criminal rather than a civil court may be the only available treatment.

A lot of laws have changed in the past two decades and the police should be able to do a lot more at this point.  In recent cases of telephone threats, even very indirect telephone threats, the police will often make a visit to the person making those statements and explain new laws about terroristic threats.  Any mental health professional should not accept the idea that something beyond a threat needs to happen before law enforcement can get involved.  The only action necessary is a threat.  What the police actually do is frequently a determining factor in whether a firearm is acquired.

5.  A secure treatment environment:  There are many aspects to this dimension including access to the physical environment, staffing, and the security arrangements.  Are there security cameras?  Are they actually monitored by security staff.  Is physical access to the environment limited to a few staff?  Most inpatient psychiatric units are locked.  I have been grateful many times that the locked door was more useful for keeping people out rather than preventing patients from leaving.

6.  An awareness that psychiatrists and other staff are killed by aggressive patients:  This happens frequently and it has been going on for a long time.  It tends not to make the papers anymore.  Here is an old New York Times article that was uncharacteristically blunt about the problem.   It described a full spectrum of homicidal aggression toward psychiatrists back in 1983.  That was the same year that I became an intern and I don't remember ever seeing this article.

7.  A functional administration:  Lack of an administrative support that prioritizes the treatment of violence and aggression and an associated systems approach to violence prevention is critical.  The appearance that a single psychiatrist is in a confrontation with a potentially violent and aggressive perpetrator needs to be avoided at all costs.  Staff splitting that encourages patients to act on aggressive wishes toward a staff member need to be avoided at all costs.  This may sound like common sense function, but in my 30 years as a psychiatrist, I have never seen a situation like this handled appropriately by administrators.  In fact, I have seen just the opposite when administrators dislike a staff person and suddenly there are rapid succession of administrative, staff, and patient problems focused on that person.    

It is very likely that the business oriented, "customer friendly" approach to patients that has been promoted by managed care has the potential for making these situations much worse.  It is hard to imagine a worse situation than to find out that a potentially aggressive patient who has threatened you is now being taken seriously by various patient representatives, customer service representatives and ombudsman.  Many of these patients realize that the state medical board is a gold mine in terms of being able to continue the harassment of the object of their aggression.  Multiple complaints against multiple parties can be filed even when it means that egregious threats made by the patient are included in the medical documentation will be sent to the medical board.

8. Dynamic issues:  There are a number of critical issues related to individual and group psychodynamics.  I have heard the term "therapeutic grandiosity" used to describe a situation where a psychiatrist failed to anticipate a dangerous situation and ended up injured or killed.  I think it is far more likely that the psychiatrist involved did not recognize different conscious states of the patient and the fact that one of those conscious states was capable of severe aggression.   Many people seem to be confused about legal definitions or reduced capacity here.  The law believes that a rational act that is internally consistent with a given psychotic state means that the person is responsible for their actions.  Every psychiatrist knows that there are mood disordered and psychotic states that result in decisions that the person would never have made if they did not have a mental illness.  One of those decisions is deciding whether or not to become aggressive toward their psychiatrist.   Making that determination can depend on very subtle findings.   If they are missed and there is an agreement to meet about an issue, especially if it is after hours the clinician may find that they are interacting with an unexpected person.  The structure of a clinic schedule and a crisis plan for that clinic can provide a basic background for not making these mistakes.

On an individual level, it is possible to view a patient's aggression as a personal failing on the part of the psychiatrist.  Many psychiatrists who have been assaulted are full of doubt about what they missed and whether the care being provided was adequate.  It is easy to lose sight of the fact that any physical aggression toward a physician is grossly inappropriate.  In the cases I have been personally aware of most of the psychiatrists were spontaneously assaulted and were not even interacting with the aggressive patient at the time.  In many cases the assaults occurred by patients who did not even know them.

There are also interpersonal dynamics that are disquieting at times.   Other staff speculating on the origins of the assault or threats, acting like the aggressive behavior can be interpreted.  This often occurs with little knowledge of the patient and their unique characteristics.  In some cases assaultive behavior is explained away on psychological grounds and the person who has been assaulted is unsupported  and alienated from the rest of the staff.  In my experience, this is a very dangerous position for the the staff to be in.  In an incredible twist, the aggressor seems to have more support than the victim even when the victim has sustained obvious injuries.   Although it has not been studied, it would not be surprising to find that staff in this position would conclude that they have no support, can expect no help, and need to arm themselves or risk annihilation.

9.  Cultural hate of psychiatrists:  There is no doubt that the haters of psychiatry have some influence here.  It is always easier to perpetrate violence against any minority group that is routinely vilified in the media and seen as a stereotyped monolithic group.  The people involved may have difficulty distinguishing symbolic hate and annihilation from the real thing.

All of these factors come in to play in considering whether or not to arm oneself to ward off a potentially homicidal threat.   From the psychiatrists I have talked with, next decision is the threshold for self defense.  Do you carry a weapon or is the threshold your front door?  Are security cameras and alarm systems enough?  I knew a psychiatrist who carried a rifle with him when he was riding his lawn mower.

The critical factor comes down to the threat assessment and all of the mitigating factors listed above.

For anyone second guessing a psychiatrist in this position, the critical question becomes:  "Where would I allow anyone to kill me?"  Is that thought compelling enough to ignore competing ethical considerations, even though there is nothing in medical ethics about a patient trying to kill their physician?  Is that thought compelling enough to ignore the law in order to protect yourself and your family?  What is your threshold for making those kinds of decisions?

For people interested in stopping this kind of aggression, the points above are all considerations of what can be done to stop it cold - long before there is any gunfire.  At that level of analysis, psychiatrists thinking of carrying guns or walking around with them is really a sign as well as an outcome.  It is a sign that multiple systems in society and medicine are either inconsistent, have failed or been corrupted.  We have these systems in place in some places and they can work.  I have seen every one of them work well at some point and prevent aggression and violence.

Fixing that larger problem should benefit everyone including the involved patients.

George Dawson, MD, DFAPA

A Gun In The Snow

A colleague of mine was out for a walk today.  It is a brisk winter day in Minnesota.  There is about 6 - 8 inches of snow cover.  He was walking across the street and found this handgun laying there.

He took a picture of the gun and called the police to pick it up.  They were there in 20 minutes.

My views on violence and gun violence are fairly well known. My recent position has been that arguing with gun advocates and the pro-gun lobby in Congress is futile.  But when I saw this posted on Facebook with the accompanying story I couldn't help but think: "Guns are so common they are falling on the ground like wallets."  Only a fool believes that this level of gun availability does not result in death and injury of all kinds including accidents, suicides, and homicides.  Only a fool believes that with this level of gun availability it is possible to prevent guns from ending up in the hands of people who are not competent to use them.  I live in a state that passed a concealed carry law that  is basically the right to carry a concealed firearm.  It passed a few years ago by tacking it on to unrelated legislation.  The gun and holster look like a common one that is sold to those who complete a brief concealed carry course.  The main argument of the concealed carry contingent was that they were supermen of sorts.  There was literally nothing that would compromise their judgment if they were carrying a handgun.  Since then there have been a number of incidents involving concealed carry owners showing that in fact problems happen.  In the most notable incident a concealed carry owner opened fire on an undercover police officer.  I think it is safe to assume that there are probably at least as many lapses of judgment involving concealed weapons as there are driving automobiles.  The main difference is that people spend more time driving.  The reporting of these incidents is not transparent and that is typical of much gun legislation.

On a worldwide basis, small arms fire is a leading cause of death and disability.  I had the opportunity to see how some of that was transacted when I lived in Africa for two years.  In travelling as little as 100 miles there were frequent roadblocks at times.  The intent of the roadblocks was not clear but each roadblock was manned by police or paramilitary personnel and everybody was heavily armed.  The American friend that I most frequently traveled with told me about a time he got out of his car to ask if there was a problem.  One of the police officers pushed the barrel of a machine gun into his chest and prodded him back to his car.  He previously served in a country where a fellow volunteer accidentally drove through a police checkpoint because there was nobody around.  It appeared to be abandoned.  He made it a short distance before he was shot through the head by soldiers out of sight up on a hill.

In the US, besides the obvious problems with the legal availability of firearms there is also the issue of the black market and stolen firearms.  Since 1994 an average of 232,000 firearms are stolen every year and 80% of those are not recovered.  Stolen guns account for 10-15% of the guns used in crimes.  The majority of guns used in crimes are purchased by proxy or so-called straw purchase sales including other tactics like diversion of guns to criminals by licensed gun dealers.  There are several common sense changes that can occur in firearm policy that might make a difference in the sheer number of firearms in the general population and their availability to criminals.

This week marked another school shooting.  It marked the anniversary of the Sandy Hook Elementary School shootings.  In practically every school shooting easy access to firearms is a major part of the problem.  There are clear models for what happens to firearm deaths when some restrictions are placed on their access.  Fareed Zakaria has a new feature Global Lessons on Guns on his Sunday news program GPS.  Last Sunday he reviewed gun policies in Japan.  Getting a license to have a firearm in Japan is very difficult.  The authorities need advance information on where it will be stored and they need a detailed floor plan of the residence where it will be stored.  In a country of 130 million people there were a total of 4 firearm homicides last year.  By contrast, in the United States with a current census of 317 million people, there were 31,672 firearm related deaths (see Table 1-1 and 1-2).  The example from Japan is also interesting because it looks at the issue of violent video games.  They are played at a higher rate in Japan than the U.S. and it obviously had no impact in the context of extremely limited gun availability.

Even though I think there are better approaches for psychiatry to focus on than strictly gun policy and confrontations with a pro-gun lobby we need a basic level of awareness that current gun laws in the US are probably not what the Framers of the Constitution intended.  I think they would be as shocked as anyone if they found a gun in the street.  They would be equally shocked to find out that 7 times as many Americans die every year as a result of firearms than died in the Revolutionary War.  (see Table 1)

George Dawson, MD, DFAPA

A Familiar Story - Another Shooting

The story is familiar and the media writes about it the same way.  A mass shooting and the shooter has anger control problems, social problems, and finally probable symptoms of psychosis.  The "ELF" considerations here were interesting.  ELF is extremely low frequency as specified in this Wiki primer that covers most of the relevant facts.  I grew up about 30 miles away from the original ELF site in Clam Lake, Wisconsin and there were plenty of conspiracy theories and environmental concerns right in the area at the time that surrounded this project including the effect of ELF on the residents.

The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted.  It is a very familiar sequence of events.  The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem.  You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration.  There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.

My response is also the same and it is basically the following:

1.  Mass homicide is a public health problem that can be addressed with public health interventions.

2.  Violence and homicide prevention can occur even in the absence of firearm legislation.

3.  Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.

4.  There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior.  That includes the assessment of threats since they are the precursors to the actual violence.

5.  A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.

6.  A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.

All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen.  The so-called mental health systems is fragmented and it has been for decades.  It is basically designed to ration rather than provide care.  That is a massive conflict of interest.  Until that is acknowledged by the politicians and advocates nothing will be accomplished.  It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care.  You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.

How many "calls to action" does the APA need?

George Dawson, MD, DFAPA

Straight Talk About the Government Dismantling Care for Serious Mental Illness

The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions.   Since I have been saying the exact same thing for the past 20 years, they will get no argument from me.  Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long.  It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man.  The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.

The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting.  President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations.  The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs.  In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:

"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass."  (page 3, par 2.)

In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.

SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders.  The idea that "the  covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s.  How is it that after the Decade of the Brain and the new Obama Brain Initiative  we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses?  How is it that apart from  some fairly obscure testimony, no professional organizations have pointed this out?  How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?

Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors.  Inpatient bed capacity in psychiatry has been decimated.  They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago.  It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions.  Where are all of the civil liberties advocates trying to get the mentally ill out of jail?

Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment.  The discharge plan in some cases is to just put the patient on a bus to another state.

Community psychiatry is a valuable unmentioned resource in this area.  In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent.  It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission.  Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed.  All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.

Civil commitment laws and proceedings are probably the weakest link in treatment.  Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources.  Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again.  Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.

Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent.  They need the same resources.  It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems.  I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health".  The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it.  If history is any indication, I don't expect anything serious to come of the criticism.  I anticipate a lot of rhetorical blow back at Dr. Torrey.  But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.

George Dawson, MD, DFAPA

E. Fuller Torrey & D.J. Jaffe.  After Newtown.  National Review Online.

White House.  Now Is The Time.  The President's plan to protect our children and our communities by reducing gun violence.  January 16, 2013.

Psychiatric care versus gun control - an expected outcome

Just in case you are keeping score the Senate voted down some modest gun control proposals last week.  The issue of coming together over mental health care to address one of the dimensions of mass shootings also did not happen.  In the political calculus, it makes sense that if legislators did not fear the gun control lobby they had a lot less to fear from a mental health lobby ambivalent about dovetailing improved mental health care with gun control.

The pro gun advocates especially the NRA have always underscored the idea that they support law abiding citizens having access to firearms.  Their mantra for years has been that if there are more obstacles to law abiding citizens getting guns then only criminals would have them.  Never mind the significant number of accidental deaths every year and the fact that firearm suicide is consistently greater that firearm homicide in this country.  That detail is not lost on psychiatrists interviewing patients who have told us that they were impulsively looking for a gun to kill themselves and the only thing that prevented it was a background check and a waiting period.  The main provision of the attempted legislation was an extension of background checks.  If the pro gun lobby believes that it is protecting the right of law abiding citizens to purchase firearms, there should be no problem at all with universal background checks.  That should cut across all venues where firearms are bought and traded.  I have not heard a single rational explanation for voting down extended or universal background checks.

Reaction to the failure of this legislation was as swift as the Sunday morning talk shows.  Bob Scheiffer interviewed family members of the victims of the Sandy Hook incident on Face the Nation.  They were clearly upset about the vote in the Senate as captured in this quote from Neil Heslin father of 6 year old Jesse Heslin one of the victims of this incident:

"....As simple as a background check, putting aside the assault weapon ban or limitation or control, it's just a stepping stone of the background check with the mental health and the school security. I think the most discouraging part of this week was to, after the vote, to see who voted and who didn't vote, support it, and realize it's a political game. It was nothing bipartisan about it, at all. And we aren't going to go away. I know I'm not. We're not going to stop until there are changes that are made."

In the vacuum of no discussion of the vote against the bill or partisan rhetoric, very little was said in the press about the money behind the vote.  OpenSecrets.org did an excellent job of showing that like most things in American politics it looks like a significant factor.  Their research clearly shows that the pro-gun lobby can outspend the gun control lobby by as much as 15:1 with most of the money going to Republicans.  There are a couple of things working against the pro-gun lobby and all of that money - public support for common sense gun measures like background checks is at an all time high.   The second factor is difficult to say out loud but in American culture you can depend on it.  There will be more incidents and the pro-gun solutions (armed guards in schools, keeping the guns out of the hands of criminals and the mentally ill) are not really solutions.  The pro-gun lobby has demonstrated that they do not take that task seriously.

George Dawson, MD, DFAPA

Senate Blocks Drive for Gun Control.  NYTimes April 17, 2013.

S. 649 Roll Call Vote

The run on guns and ammunition - is this mass psychogenic illness?

I was watching my usual Sunday morning news programs two weeks ago when I heard that Wal-Mart had such a run on their ammunition supply customers that they were limiting sales to three boxes per customer per day.  That brings up the image of tens of thousands of people going to Wal-Mart every day to buy their three boxes of ammo.  What is it about the American psyche that drives this behavior and the recent stockpiling of guns?

It reminded me of the Y2K situation from over a decade ago.  Do you remember that scenario?  In the antithesis of the Terminator series, computers would be crippled by inadequate programming to account for the change to the 21st century.  The power grids would collapse.  The logistics of food and medical supplies would be paralyzed.  There would be chaos in the streets.  In Minnesota in the middle of winter that translated to a run on electrical power generators.  It got to the point that one of the big home stores cancelled their return policy for generators.  I never noticed it but I wonder if the generator aisle at the Home Depot ever looked like this gun shop display.

All of the signs point to this being a record year for gun and ammunition sales.  The National Instant Criminal Background Check System (NICS) has a record number of checks.  Nine of ten of the top highest days and 10/10 of the top ten highest weeks for gun checks since the system was started in November 1998 have occurred within the past two months (see below).   The charts below give the NICS checks month by month since then and the actual listing of top days and weeks for checks.  Although there is usually a disclaimer about how checks do not necessarily equate to gun purchases, the issue has been studied and for each check there is about a 70% chance that a firearm will be acquired taking into account all of the possible outcomes. (click to enlarge)

Another perspective comes from the Bureau of Alcohol, Tobacco, Firearms, and Explosives.  They keep a record of firearm manufacturing in the US by the type of firearm and also whether or not a firearm is exported.  The data going back to 1998 is available on their web site.  I plotted that data for rifles, pistols, revolvers, and shotguns on the following graph.  Some interesting trends noted include the fairly recent increase in rifle production. There were relatively flat revolver and shotgun sales, and a sharp increase in pistol production over the past decade.   The year 2004 is also an interesting inflection point for rifle sales since that was the year that the ten year ban on assault rifles expired.   Without knowing the exact breakdown of rifle sales, the rise at that point combined with flat rate of shotgun sales suggests that the rising rate represents sales of assault rifles or military style weapons that are not necessary for hunting.

All of the signs point to a greater prevalence of guns in homes and communities especially hand guns.  Not only that but it appears that Americans are arming themselves at a much higher rate than at any time since we started to keep these statistics.  They also appear to be arming themselves using handguns and possible military style weapons that are not typically used for hunting.  Hunters are frequently mentioned in NRA and pro-gun rhetoric but they certainly are not responsible for the huge increase in hand gun sales.  If we are ruling out hunters who is buying the guns?

My guess is that it comes down to people arming themselves because they believe that they need protection.  Although a previous post here clearly shows that the violent crime rate is at an all-time low there are numerous self protection ideologies.  At one time or another I have heard the following arguments:

1.  Protect yourself against violent criminals (even though there are fewer of them and they seem to be committing fewer violent crimes than at any point in the past 30 years).

2.  Protect yourself against terrorists.  My guess is that terrorists would not be foolhardy enough to walk into any well armed American neighborhood and start a gun fight

3.  Protect yourself against the government.  This is an interesting argument because it basically is the same thing as treason.  When I argued that point with a famous gun advocate he pointed out that it would depend on "who won".  Some conservative and liberal politicians of both parties have made this argument, including Minnesota's well known liberal Senator Hubert H. Humphrey.  The basic argument is that if the government becomes completely unresponsive to the people for one reason or the other - we should have enough firepower to overcome it.  I guess if we can't vote the bums out - there is always another way.

4.  Protect yourself against your neighbors.  This is the survivalist argument.  The survivalists believe that we are always "9 meals away from chaos".  It is therefore logical to stockpile food.  When the apocalyptic event happens, you need enough guns and ammo to shoot anyone who threatens you or your food stockpile.

5.  Protect yourself against the zombies.  That's right - you thought the zombie apocalypse was just fiction.  I happened to catch an episode of Doomsday Preppers that was full of information ranging from how zombies might scientifically happen to staircase design that would slow them down long enough so that you could administer the old "double tap". 

An inspection of the above list suggests that there are many more imagined than real threats.  Possibly several orders of magnitude greater if you are considering that all of your neighbors who ignored your warnings about the apocalypse are either coming for your food or have contracted the virus that turns them into zombies and want to eat you for food.  In that scenario - how much ammo is enough?  All of this would be more fodder for the film industry if it was not true at some level.  Very few real threats and many imagined would seem to be driving the current gun buying frenzy.  After all - what would happen if any of the mass scenarios unfolded and we did not have enough guns and ammo?

I don't want to go too far out onto a limb here.  For all of you DSM5 detractors - don't worry there is no diagnostic category to critique.  I think that there is room for studying the problem, but it would involve collecting data from the gun purchasers and we all know that would not fly.  Anyone knows that if you can be identified - the government can kick your door down and take your guns.  

George Dawson, MD, DFAPA

FBI NICS Web Site

FBI Instant Background Checks November 30, 1998- January 31, 2013.

ATF Annual Firearms Manufacturing Report and Export Report 2011.

ATF Statistical Web Site