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

Anger and Projection Are Not Political, Racial Or Gun Control Problems

Anger and projection are mental and public health problems.

The homicides of two young broadcast journalists yesterday continues to stimulate the same media response that it always does - mourning the victims, discussing the tragic aspects of the event, and doing a media profile of the perpetrator.  Anyone who has read this blog over the last three years knows my positions on this.  Lengthy posts and academic references don't seem to matter so I thought that I would keep this brief and reiterate the main points before it becomes the usual media circus about gun control and speculating about the perpetrator's mental state.   The most rational analysis considers the following points:

1.  This is first and foremost about the mental state of the perpetrator:

Without the perpetrator there is no tragedy.  Preliminary descriptions in his own words that he was a powder keg that was waiting to go off.  He had a pattern of angry conflicts with coworkers that severely complicated his life, led to job loss, and ongoing conflicts.  I heard a detailed analysis of an alleged pattern of behavior that results in this kind of homicide on the morning news today and it was too pat.   It sounded like the old "stages of grief" model that people used to adhere to.  I think there is a lot of confusion out there about what is normal anger and what kind of anger is pathological.  Anger is a socially and culturally difficult construct.  In many places like my home state of Minnesota it is generally unacceptable.  It is difficult to recognize when anger becomes a problem, if your reality excludes it as a possibility.

Anger is a problem when it is persistent and pervasive.  Normal anger is transient and does not persist for days, weeks or longer.  It is necessarily transient because it can activate physiological processes like hypertension that are not conducive to the health of the individual.  Persistent anger also gets in the way of normal social interactions that all people need in order to function properly.  Human beings are undeniably social animals and we do not function well if we are isolated or cut off from one another.  Anger tends to automatically focus people on an outside source for their problems and frustration while minimizing their own potential role in the process.  Persistent anger does not allow for the necessary productive interactions with family members, coworkers, or in many cases casual contacts in everyday life.

Projection is the attribution of a feeling state or problem to another person.  It is commonly experienced when observing a person blame other people or circumstances for problems they are having in life.  How rational that level of blame seems may be an indication of the severity of the problem.  In my years of treating people in inpatient psychiatric units, it was rare to encounter a person who did not see me as the root of their problem, even though I had barely met them, had nothing to do with why they were in the hospital, and was the person charged with helping them get out.  Some might think that was just a part of me representing an institution, but that goes out the window when the reasoning being given is that I am white or jewish or racist or I am physically attracted to the patient.  Those were typically the mildest accusations.  In many cases, this anger and projection was obvious to family members and coworkers for months or even years before the person was admitted to my unit.  Threats of physical violence or actual physical violence in these situations was common.

2.  This is a public health problem:

People with anger control problems and projection generally do not do well in life.  At the minimum these problems are significant obstacles to a successful career and social life.  One public mental health focus should be on optimizing the function of the population and preventing this social morbidity that is also associated with somatic morbidity and mortality.  In some cases, these mental states are also precursors to violence including suicide and homicide.  In some cases they have led to mass shootings.

There are very few people who talk about this kind of violence and the associated mental state as a preventable or treatable problem.  Part of the issue is that anger is socially unacceptable and it seems like a moral issue.  We should all learn how to control our tempers and keep ourselves in check.  If we don't, well that's on us and we should be punished for it.  Another part of the problem is that some people want to see it as a strictly mental health problem and turn it into a problem of prediction.  The argument then becomes the inability to predict who will "go off" and harm someone.  The additional issue that will heat up at some point is the gun control issue.  Any reasonable person will conclude that gun access in the US is too easy and the amount of firearm injuries and deaths are absurdly high for a sophisticated country.  That said, there appears to be no practical way to alter this problem within our current legislative system.  Even if all guns were removed, it would not stop the problem of people with anger control problems and projection from not doing well in life or harming innocent victims.

To address the problem, we need to take an approach that is similar to suicide prevention.  I am not talking about screening.  I am talking about identifying people at risk.  The best way to do that is to develop strategies to help them self-identify and request help or to help people in their lives assist them in getting help.  Typical ways this works in suicide prevention is public service announcements, volunteer hotlines, referrals through law enforcement and the court system, and referrals through the schools.  Suicide is also identified as a major public health issue and as such it is a focus of many organizations that do advocacy and intervention work in the area of mental health.  There are no similar resources for anger and violence prevention.

That is my basic message involving the most recent incident of preventable homicide in the United States.   I wanted to get this out after seeing just one broadcast on the issue and before I saw too many stories politicizing the incident.  I think that the factors that have resulted in lack of action in this area are obvious and several of them will be on display over the next few days.

As a psychiatrist who has worked in this area for nearly 30 years, I can say without a doubt that this unnecessary loss of life can be prevented and preventing it does not require psychiatric services, but it does require people who are willing and able to address the problem.

We just have to stop pretending that it can't be stopped.


George Dawson, MD, DFAPA



Supplementary:

1.  Previous violence prevention posts here.

2.  Previous homicide prevention posts here.





    

The Real Lesson of the George Zimmerman Trial

The latest reality based media event has been the George Zimmerman trial.  Zimmerman shot and killed Trayvon Martin and most media outlets have reviewed the details of the case including courtroom reenactments of the physical confrontation that resulted in the shooting.  The secondary story is how the public will react to a verdict.  A tertiary story that is building at this time is media criticism - has the media gone to far and should there be cameras in the courtroom?

My point is not to reconstruct the arguments of case but to speculate about how unnecessary violent confrontations may occur in the first place.  They do occur frequently and the majority of those confrontations are not covered by the press.  You might read about them in your local newspaper or if you are a health professional you have probably encountered the victims or the combatants.  In my experience, the level of violence and the resulting injuries are always surprising.  People are punched in the face or head and die instantly.  People are struck or pushed and strike their heads on the way to the ground and die.  People are severely beaten on the street for either a trivial reason or the victims of gang violence and die or sustain disabling injuries.  Weapons are used against friends and family.  It is as if people think that you can engage in Hollywood style mayhem and in the end only the bad guys suffer.  The idea that the human body, especially the brain is extremely vulnerable and needs to be protected seems to be suspended.  But that in itself is not the root cause of the problem.

Violence and aggression as a means to resolve interpersonal conflict has been with the human race since prehistoric times.  I have found that Keeley offers the best historical account and analysis at the level of conflicting villages, city-states, and nations.  His original intent was to dispel the notion of the noble savage or the peaceful prehistoric man living in an idyllic situation.  He ends up showing that warfare has been a remarkably constant feature across time.    From his text:

"According to the most extreme views, war is an inherent feature of human existence, a constant curse of all social life, or (in guise of a real war) a perversion of human sociability created by the centralized political structures of states and civilizations.  In fact, cross cultural research on warfare has established that although some societies that did not engage in war or did so extremely rarely, the overwhelming majority of known societies (90-95%) have been involved in this activity." (p 27-28)

In reviewing some of the smaller pacifist pastoral societies,  Keeley cites their low population density as well as their strong moral distaste for violence (p 31) as a likely reason that the Semai could return to a peaceful existence after being recruited by the British to fight against Communist insurgents in the 1950s.  In his chapter "Crying Havoc-The Question of Causes", Keeley takes a fairly detailed look at how war starts as a combination of psychological and political factors starting off with a conflict between two villages where one village owed the other village a debt.  He demonstrates how that that conflict escalates to the point of violence and death for several reasons.  He cites prestige, theft,  adultery, and poaching as common reasons for conflicts with aggression resulting in death.  He concludes that the specific information from an archaeological standpoint is generally difficult to discern and considers broader contexts.

I think the implicit strength of Keeley's work is that he does have a lot of information on warfare and conflict in small and large societies and through all of that information the common thread is that humans resort to violence as a way to resolve conflict, even in situations that are relatively trivial and could easily be resolved by other means.  I  have made that observation repeatedly in clinical situations and the only exceptions are where the violence is driven by a psychiatric disorder.  It is also obvious that learning other strategies can definitely occur often times for the worst possible reasons.  An example is an aggressive man with antisocial personality disorder who typically gets what he wants by threatening or harming people.  If he survives long enough, he may get to the point where that is a losing tactic and he becomes less aggressive with age.  A more common example is the case of people referred to anger control groups through their contact with law enforcement or the courts.  Many find that the strategies they learn in these groups are very effective.

So what is the real lesson in this case?  The real lesson is that this violent confrontation did not need to occur.  All of the energy being expended in the debate about who was the victim and whether or not legal penalties should be assigned misses that point.  It should be fairly obvious that each side can construct a detailed narrative of what happened and how that should affect the outcome.  My courtroom experience has left me with the impression that it is possible that neither narrative is an entirely accurate representation of what happened.  Who would want their future decided by those circumstances?

All of the sensational coverage by the press misses even more widely.   Solving conflicts between people by aggression and homicide is a strategy of primitive man.  It arose out of a time before there was a legal system or designated police.  It came from a time where there was no recognition that every person is unique and society may be less if that unique person is lost.  Until there is the realization that violent confrontations are a toxic byproduct of of our prehistoric ancestors and that they are no longer necessary - there will continue to be unnecessary tragedies.  Society is currently complex and aggression will never be a final solution.  Coming up with better solutions at this point is the next logical step.

George Dawson, MD, DFAPA

Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997

More on Homicide Prevention – LA County Style

I have been developing a theme of how to prevent homicide and mass killing for more than a decade.  As previously posted, I think that this needs to be done independent of the firearms issue with a public health focus on both primary and secondary prevention.  There have been a couple of developments recently that I would like to highlight and whether or not they are consistent with the public health approach.

The first is an article in the NY Times today on a unique approach to school threat assessment and intervention.  The article describes LA County’s School Threat Assessment Response Team.  Several threat scenarios are described that trigger a multidisciplinary response from team members representing law enforcement, school officials, and mental health.  The way the program is described it is unique in terms of engagement.  Threats at school generally result in one dimensional and fragmented approach to the problem.  The school has a protocol that may result in suspension.  Referral to mental health providers is frequently a limiting step due to the lack of appointments, insurance problems, or debate over whether the school system or the health care system is responsible for assessment and treatment.  This patchwork system is a set up for people with severe problems falling through the cracks.

The LA County response is for the team to make a rapid same day assessment at the point of the threat and at the student’s home including looking at their room.  How many times have we read about the marginal teenager who is thrown out of school for threatening behavior and they end up sitting in their room focused on the same thought patterns or watching other forms of violent activity on the Internet or in video games?  Getting right into that environment seems like a powerful intervention to me and one that is likely to yield better results.  The main reason for failure in situations where a threat has been identified is that lack of follow up.    People who are threatening and aggressive are not likely to care if they are thrown out of school and they are not likely to follow through with mental health interventions.  The response team also spends time educating people about how to communicate in emergency situations where there are many misunderstandings about confidentiality.

The LA approach is innovative and exactly what is needed to assess and intervene in crisis situations involving threats and dangerous behavior.  In situation after situation, tragedies occur when people people come to the attention of someone and there is no clear map for assessment and treatment.  That is true in the school system, in colleges and universities, in the workplace and in family situations.  I have personally talked with people who said that they either did not know what to do or they actively tried several resources and were told that there were no appointments available or that the person was not dangerous enough to treat and unless they agreed to a voluntary assessment and treatment that nothing could be done.  But it doesn’t stop at that point.  I am also aware of situations where there clearly was enough evidence that the person was dangerous enough to meet criteria for an emergency assessment but it was not done of the person was released for the emergency department.  In many of these cases there was an adverse outcome.  What is the problem?

There is a significant bias against aggressive and violent people.  To some extent that bias is self protective.  Any reasonable adult knows the obvious advantages of avoiding conflicts or even irrational behavior.  There are always plenty of stories in the news about the lack of Good Samaritans in situations where an aggressive act is being perpetrated in public.  Many psychological explanations of this behavior are offered but I think the obvious motivation is avoiding the conflict and possible injury.  That same code of silence often applies in cases where there have been sudden changes in behavior and the person involved has a treatable problem.  A second level of bias is the moralistic approach to aggressive and violent behavior that equates this behavior with bad moral conduct.  That applies in situations where criminals use aggression to intimidate people and get what they want.  It does not apply when the aggression is a symptom of mental illness.

The bias extends beyond members of the general public.  The health care system is activated by a legal concept called “dangerousness” or “imminent dangerousness”.  Every state has different statutory requirements and those statutes are interpreted on a highly variable basis across every county in the state.  In some counties it comes down to some of the public officials involved seeing themselves as protectors of people’s rights.  In other counties, assessment and treatment are more of a priority.  At the level of the health care system there is another layer of bias.  The overwhelming bias these days is that people should not be assessed or treated in a psychiatric facility for more than 4 or 5 days and any assessment or treatment should be kept to the bare minimum.  It is easy to find different clinicians make entirely different decisions when presented with the same potentially dangerous patient.  The end result is a patchwork of acute care settings where people can go for help.  Because of all the biases involved unless an aggressive act has been committed the likelihood of an intervention occurring is basically a coin toss.

That is why the LA County response is so important.  It is an intervention that activates a rational response to threats from people who are likely in distress and possibly mentally ill.  There is no dangerousness standard initially and that is a critical departure from the current nonsystem.  The goal of the LA County response is to engage the person and their social network and not make a one-time assessment and decide to admit or discharge the patient based on a dangerousness concept.  The LA County response is unique in that it is based on behavior and the goal is to help the person involved rather than decide on whether or not they should be committed.  The overall approach is very similar to community psychiatry case management teams except LA County teams seem to have more latitude because they are not limited initially by commitment standards.

The is an excellent approach to the problem and I hope that it is researched, expanded to mental health crisis teams and widely adopted if effective.  I don’t know why it would not be effective.

George Dawson, MD, DFAPA

Erica Goode.  Focusing on Violence Before It Happens.  NY Times March 14, 2003.

"The only thing that stops a bad guy with a gun is a good guy with a gun"

That is a direct quote from the NRA's chief lobbyist Wayne Lapierre.  In the same NYTimes piece he goes on to say that declaring our schools gun free zones serves only: "“tell every insane killer in America that schools are the safest place to effect maximum mayhem with minimum risk.”  There has been some mild outrage in response to this comments but I don't know what people would expect from the NRA.  They see guns as a solution to everything.  They literally believe that with guns there is less crime despite the hard data that points to the fact that the USA has the highest (by far) homicide rate by firearms, the highest rate of gun ownership, and the highest rate of assault deaths of any of the top 30 countries of the Organization for Economic Cooperation and Development.  In fact, this NY Times graphic of the data shows that over half of the homicide rate is firearm related.  The total homicides in the US at 9,960 is nearly seven times greater than the total of all the other countries on the list.  The total number of suicides by firearms greatly exceeds this number (18,735 in 2009).  It seems to me that the gun data suggests that we currently have maximum mayhem with maximum risk.

Getting back to the proposed NRA solution.  Let's look at the arithmetic first.  Just considering the number of public schools in the US, current data from the National Center for Education Statistics puts that number at 98,817.  Assuming a cost of one armed guard per school with vacation coverage and benefits I would conservatively estimate a cost of about $100,000 per year or a total of about $9.8 billion dollars per year.  That is a substantial outlay of capital for what is an unproven strategy.  According to the Wikipedia list there have been 40 school shootings since 1989.  Using a a mean number of schools during the period (or about 91,638) would mean that the odds of one of these armed guards encountering a shooter would be about 2/91,638 on an annual basis.  The Transportation Security Administration responsible for airport security has a total budget of  $7.7 billion and they cover 450 airports but confiscate 1,300 firearms and 125,000 prohibited items per year.  $929 million of the TSA budget is for the Federal Air Marshal Service that assigns agents to commercial flights.  To put an armed guard in the schools would roughly cost what it costs to secure air travel in the US.  The main difference would be that school guards might have a much lower level of vigilance than air travel security and they would need to be very vigilant to head off a sudden and potentially very lethal attack.

Arithmetic aside, there is also the question of associated costs.  In medicine we are familiar with the screening arguments for breast and prostate cancer.  There is always a false positive and false negative cost.  With false positive PSAs and mammograms there is the ordeal of unnecessary biopsies and exposure to other unnecessary tests.  There is no way to estimate the impact of armed guards at schools.  Currently there are about 500,000 violent crime and over a million thefts committed against teachers in America's middle and high schools.  In a previous Institute of Medicine report,  the authors found that a  "substantial number of boys" carry firearms in schools.  That same study reported:

"Despite all this effort to keep guns from children  the committee was somewhat astounded at the ease with which the young people in these cases acquired the weapons they used.  Only in the Jonesboro case were the powerful weapons in the home of one of the too well secured for them to access.  But it was easy to defeat the security measures of another relative and get hold of a powerful semiautomatic rifle with a scope.  In general, it is easy for young teens to circumvent both the law and informal controls designed to deny them weapons they use in their crimes." (ref 1)

There is also the risk of unintentional discharge of weapons.  The New York City Police Department keeps a public record of all weapons discharges from its 33,497 police officers.  According to this report there have been 15-27 "unintentional discharges" per year over the past ten years.  With a school workforce nearly three times as large and possibly less vigilant than an NYPD officer that is potentially a lot of accidental discharges.   How many are acceptable in and around our schools?  The false negative/false positive cost of putting  armed guards into schools based on these factors is really unknown.  

Considering this problem has also led me to think about some epidemiological concepts that we were all taught in medical school.  Primary prevention measures are designed to reduce the incidence of new cases of disease.  Secondary prevention is focused more on people who are identified as being at risk but who are unaware of the fact that they may have the problem.  Tertiary prevention occurs after the problem is declared.  In the case of suicidal or homicidal behavior that means after the critical incident occurs.  This paper looks at these concepts in the case of suicidal behavior.  As far as I can tell there has been no exhaustive look at a timeline of all of the preventive factors that occur prior to mass shooting events or school violence events.  The usual method of analysis is looking at cases for a common profile and as the IOM report showed - there was none.

This analysis cannot predict whether the NRA stand on guns in schools will be protective or not.  It is much more complex than a statement that guns are a solution to gun crimes.  Based on what we know about these situations a key strategy is preventing the shooter from picking up the weapon in the first place.

George Dawson, MD, DFAPA

1.  National Research Council and Institute of Medicine. (2003) Deadly Lessons - Understanding Lethal School Violence.  Case Studies of School Violence Committee.  Mark H. Moore, Carol V. Petrie, Anthony A. Braga, and Brenda L. McLaughlin, Editors.  Division of Behavioral and Social Sciences and Education.  Washington, DC: The National Academies Press.

2.  Ganz D, Braquehais MD, Sher L (2010) Secondary Prevention of Suicide. PLoS Med 7(6): e1000271. doi:10.1371/journal.pmed.1000271

3.  New York City Police Department.  Annual Firearms Discharge Report 2011.

4.  Meet  the Press Transcript. Sunday December 23, 2013.  Wayne LaPierre discusses current NRA positions on school safety and gun control.

Homicide Debate Goes Further Off the Rails

Apparently broadcast news is about as reliable as the Internet these days.  I was watching an "expert" on the weekend discuss the connection between homicide and antidepressant medications.  He apparently believed that there was one.  I understand that Sanjay Gupta made a similar comment today on CNN.  The misinformation is flying out there.  There are several political interests that would like that statement to be true and they appear to be out in full force. What is the short answer to the association between antidepressants and homicide?  Who can you believe?

Well there is always the scientific approach and a review of the medical literature.  Admittedly the literature is a lot drier and less entertaining than Dr. Gupta.

There is also simple arithmetic   The American media like to give the impression that violent crime and homicide are at epidemic levels.  It is always a shock when people discover that in fact we are at a 30 year low:

The homicide rate has actually declined from 10.2 per 100,000 in 1980 to 5.0 per 100,000 in 2009.  What are the odds of that happening if a major new cause of homicide is being added at the same time (namely antidepressants).  How does that compare with antidepressant use?  A recent study estimated that from 1996 to 2005, the number of Americans older than 6 years of age in surveyed households who received at least one antidepressant in the year studies increased from 5.84% in 1996 to 10.12% in 2005.  From the table there was a 24% reduction in the homicide rate during a time that antidepressant use nearly doubled.  One in ten Americans received an antidepressant prescription   The authors of this study noted this trend was broad based and correlated with a lower percentage of people receiving psychotherapy.

But what does that tell us about the observation that antidepressants cause homicide?  Technically there is no current way to demonstrate causality from a negative correlation between homicide rates and the rate of people taking antidepressants.  A large scale significant negative correlation between antidepressant use and lethal violence over a 15 year period has already been reported in the Netherlands.

What about the commentator suggesting that the toxicology of homicide perpetrators shows that they can have psychiatric drugs present that explain their homicidal behavior.  In fact, a study looking at that issue showed that 2.4% of 127 murder-suicide perpetrators had toxicology that was positive for antidepressants.  That is a lower than expected rate of antidepressant use than in the general population.   In a study of elderly spousal homicide-suicide perpetrators, depression was seen as an antecedent to this act but none of the perpetrators tested positive for antidepressants.

Given these observations any claim that antidepressant or any psychiatric drug causes homicidal behavior needs to be backed up with some hard data.  I don't mean a series of cases reported by somebody to make a point and I don't mean a legal decision where lawyers and judges can pretend that scientific data do not exist and make a decision about what they hear in a court room.  I also do not mean listening to somebody claim that we will never know the real relationship until we conduct "prospective double blind placebo controlled studies" of homicidality as a medication side effect.  If it isn't obvious, that study would by definition be unethical and would not pass the scrutiny of any human subjects committee.

Anyone with potential homicidal thinking needs close supervision and treatment.  They may need inpatient treatment in a unit that specialized in treating homicidal thinking and behavior.  Any clinician working in these settings will tell you that the people being treated generally come in with aggressive and violent thoughts and behavior before they take any medication.  If they have positive toxicology associated with homicidal thinking it is generally alcohol or an illicit drug like cocaine or methamphetamine.  Anyone with this problem also needs close monitoring and management of medication side effects.  Antidepressants can cause agitation and restlessness.  There are some people who do not benefit from antidepressants.  In the case of persons with the potential for aggression and suicide the medication response may need to be determined in a controlled environment before they can be safely treated.  Like all medications antidepressants are not perfect medications and they need to be administered by an expert who can provide effective treatment while managing and eliminating any potential drug side effects.

George Dawson, MD, DFAPA

"Preventing Violence: Any Thoughts?"

The title of this post may look familiar because it was the title of a recent topic on the ShrinkRap blog.  That is why I put it in quotes.  I put in a post consistent with some the posts and articles I have written over the past couple of years on this topic.  I know that violence, especially violence associated with mental illness can be prevented.  It is one of the obvious jobs of psychiatrists and one of the dimensions that psychiatrists are supposed to assess on every one of their evaluations.  It was my job in acute care setting for over 25 years and during that time I have assessed and treated all forms of violence and suicidal behavior.  I have also talked with people after it was too late - after a homicide or suicide attempt had already occurred.

The responses to my post are instructive and I thought required a longer response than the brief back and forth on another blog.  The arguments against me are basically:

1.  You not only can't prevent violence but you are arrogant for suggesting it.
2.  You really aren't interested in violence prevention but you are a cog machine of the police state and inpatient care is basically an extension of that.
3.  You can treat aggressive people in an inpatient setting basically by oversedating them.
4.   People who are mentally ill who have problems with violence and aggression aren't stigmatized any more than people with mental illness who are not aggressive.

These are all common arguments that I will discuss in some detail, but there is also an overarching dynamic and that is basically that psychiatrists are arrogant, inept, unskilled, add very little to the solution of this problem and should just keep quiet.  All part of the zeitgeist that people get well in spite of psychiatrists not because of psychiatrists.  Nobody would suggest that a Cardiologist with 25 years experience in treating acute cardiac conditions should not be involved in discussing public health measures to prevent acute cardiac disorders.  Don't tell anyone that you are having chest pain?  Don't call 911?  Those are equivalent arguments.  We are left with the curious situation where the psychiatrist is held to same medical level of accountability as other physicians but his/her opinion is not wanted.  Instead we can listen to Presidential candidates and the talking heads all day long  who have no training, no experience, no ideas, and they all say the same thing: "Nothing can be done."

It is also very interesting that nobody wants to address the H-bomb - my suggestion that there should be direct discussion of homicidal ideation.  Homicidal ideation and behavior can be a symptom.  There should be public education about this.  Why no discussion?  Fear of contagion?  Where does my suggestion come from?  Is anyone interested?  I guess not.  It is far easier to continue saying that nothing can be done.  The media can talk about sexual behavior all day long.  They can in some circumstances talk about suicide.  But there is no discussion of violence and aggression other than to talk about what happened and who is to blame.  That is exactly the wrong discussion when aggression is a symptom related to mental illness.

So what about the level of aggression that psychiatrists typically contain and what is the evidence that they may be successful.  Any acute care psychiatric unit that sees patients who are taken involuntarily to an emergency department sees very high levels of aggression.  That includes, threats, assaults, violent confrontations with the police, and actual homicide.  The causes of this behavior are generally reversible because they are typically treatable mental illnesses or drug addiction or intoxication states. The news media likes to use the word "antisocial personality" as a cause and it can be, but people with that problem are typically not taken to a hospital.  The police recognize their behavior as more goal oriented and they do not have signs and symptoms of mental illness.  Once the psychiatric cause of the aggression is treated the threat of aggression is significantly diminished if not resolved.

In many cases people with severe psychiatric illnesses are treated on an involuntary basis.  They are acutely symptomatic and do not recognize that their judgment is impaired.  That places them at risk for ongoing aggression or self injury.  Every state has a legal procedure for involuntary treatment based on that principle.  The idea that involuntary treatment is necessary to preserve life has been established for a long time.  Civil commitment and guardianship proceedings are recognition that treatment and in some cases emergency placement can be life saving solutions.

The environment required to contain and treat these problems is critical.  It takes a cohesive treatment team that understands that the aggressive behavior that they are seeing is a symptom of mental illness.  The meaning is much different than dealing with directed aggression by people with antisocial personalities who are intending to harm or intimidate for their own personal gain.  That understanding is critical for every verbal and nonverbal interaction with aggressive patients.  Aggression cannot be contained if the hospital is run by administrators who are not aware of the cohesion necessary to run these units and who do not depend on staff who have special knowledge in treating aggression.  All of the staff working on these units have to be confident in their approach to aggression and comfortable being in these settings all day long.

Medication is frequently misunderstood in inpatient settings.  In 25 years of practice it is still very common to hear that medication turns people into "zombies".  Comments like: "I don't want to be turned into a zombie" or "You have turned everyone into zombies" are common.  I remember the last comment very well because it was made by an observer who was looking at people who were not taking any medication.  In fact, medication is used to treat acute symptoms and in this particular case symptoms that increase the risk of aggression.  The medications typically used are not sedating.  They cannot be because frequent discussions need to occur with the patient and a plan needs to be developed to reduce the risk of aggression in the future.  An approach developed by Kroll and MacKenzie many years ago is still a good blueprint for the problem.

There is no group of people stigmatized more than those with mental illness and aggression.  It is a Hollywood stereotype but I am not going to mention the movies.  This group is also disenfranchised by advocates who are concerned that any focus on this problem will add stigma to the majority of people with mental illness who are not aggressive or violent.  There are some organizations with an interest in preventing violence and aggression, but they are rare.

At some point in future generations there may be a more enlightened approach to the primitive thoughts about human consciousness, mental illness and aggression.  For now the collective consciousness seems to be operating from a perspective that is not useful for science or public health purposes.  There is no better example than aggression as a symptom needing treatment rather than incarceration and the need to identify that symptom as early as possible.

George Dawson, MD, DFAPA

Wartime atrocities

The recent mass murders in Afghanistan and the analysis of the events in the press highlight my contention from an earlier post that the press really does not do a good job in these situations. We can expect a continued exhaustive risk factor analysis and discussions by various pundits. The accused soldier clearly had a lot of exposure to combat stress, there is a history of traumatic brain injury, there is a possible history of substance abuse, and there are multiple psychosocial factors. So far we have seen the statements by people who knew him describing this event as completely unpredictable based on his past behavior. The debate will become more polarized as the lawyers get involved. The real truth of the matter is never stated.

What we know about these incidents is more accurately described by anthropologists than psychiatrists or psychologists. The best book written on this subject is Lawrence Keeley’s War Before Civilization.  In that book Dr. Keeley explores the contention that primitive peoples were inherently peaceful compared to modern man and a warfare that was waged was brief, fairly nonlethal, and stereotypic. In order to explore that theory, Dr. Keeley ends up writing a fairly definitive book on the anthropology of warfare. There are more lessons in that book about war and peace then you will ever hear on CNN or in the risk factor analysis that is produced in the popular media.

So what do we know about the mass murder of civilians during warfare? The first thing we know is that it is commonplace. It happens in every war and no military force despite their level of training is immune to it.  In prehistoric times, the most frequent scenario was a surprise attack on a village with the goal of killing as many inhabitants as possible. In Keeley's review, that number was generally around 10% of the population and that could have devastating consequences for a particular tribe including the complete dissolution.

Keeley also makes the point that: “Only the "rules of war," cultural expectations, and tribal or national loyalties make it possible to distinguish between legitimate warfare and atrocities.”  He gives the examples of Wounded Knee and My Lai as well as larger scale bombings of Hiroshima and Dresden.  My Lai was a highly publicized incident from my youth. It occurred during the Vietnam War when the US Army massacred hundreds of Vietnamese noncombatants – largely women, children, and old men.  In that situation, 26 soldiers were charged and only one was convicted. The convicted soldier served 3 1/2 years under house arrest.

In addition to outright killing, mutilations of bodies and the taking of body parts as trophies continue to occur in modern civilized warfare in much the same way that these practices occurred in primitive warfare.  Haley reported on a series of Vietnam veterans seen in psychotherapy and the special problems that exist in patients who have been exposed to or participated in wartime atrocities. Based on the literature at the time she suggested that the war in Vietnam resulted in a disproportionate number of atrocities.

My current final analysis of the situation is that there are important social and cultural determinants of war and the inevitable wartime atrocities. Risk factor analysis and analysis of individual biology is very unlikely to provide an explanation for what occurred. The moral, legal, and political environment has changed since Vietnam and that is obviously not a deterrent. A comparison of the final legal charges and penalties in this case with what happened in Vietnam will be instructive in terms of just how far those changes come. If there is a conviction, there will be a lot of pressure to portray the convicted soldier as very atypical and probably as a person who underwent a significant transformation of his conscious state.  There will be many theories. The idea that this transformation predictably occurs during warfare will not be discussed. I have already heard some experts talking about the thousands of soldiers who go though similar situations and seem to do just fine.

The best approach to these events is a preventive one that includes minimizing the exposure to war instead of being involved in the longest war in American history.  I don't expect that much will be said about that either.

George Dawson, MD

Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

Haley SA. When the patient reports atrocities. Specific treatment considerations of the Vietnam veteran. Arch Gen Psychiatry. 1974 Feb;30(2):191-6.

Violence and Gunplay - Why Nobody is Informed by the Media Anymore

Mass shootings have been a phenomenon of my lifetime.  I can still clearly remember the University at Texas-Austin shootings that occurred  on August 6, 1966. A single gunman killed 16 people and wounded 32 while holed up on the observation deck of an administrative building until he was shot and killed by the police. I first read about it in Life magazine. All the pictures in those days were black and white. Some of those pictures are available online on sites such as "Top 10 School Massacres.”  I generated this timeline of mass shootings when Google still had that feature in their search engine. 

The problem of course is that the mass shootings never really  stop.  In the USA, the press is so used to them that they seem to have a protocol.  Discuss the tragedy and whether or not the perpetrator was mentally ill, had undiagnosed problems or perhaps risk factors for aggression and violence.  Discuss any heroic deeds. Make the unbelievable statement that the victims were "in the wrong place at the wrong time."  And then move on as soon as possible.  There is never a solution or even a call for finding one.  It is like everyone has resigned themselves to to repetitive cycles of gunfire and death.  It is clear that the press does not want to see it any other way.

When you are practicing psychiatry especially in emergency situations and hospitals, you need to be more practical.  When I took the oral boards exams back in 1988 and subsequently when I was an examiner, one of the key dimensions that the examiners focused on was the assessment of dangerousness.  Failing to explore that could be an exam failing mistake.  Any psychiatric inpatient unit has aggression toward self or others as one of the main reasons for admission to acute care and forensic settings.  With the recent fragmentation and rationing of psychiatric services, many people who would have been treated in hosptials are diverted to jails instead.  That led one author to describe LA County jail as the country's largest psychiatric facility.  

I have introduced the idea of looking for solutions into professional and political forums for over a decade now and it is always met with intense resistance.  Some mental health advocates are threatened by the idea that it will further stigmatize the mentally ill as violent.  Many people consider the problem to be hopeless.  Others see it as the natural product of a heavily armed society and no matter what side you are on that argument - that is where the conversation ends.

In an attempt to reframe the issue so that this impasse could possibly be breached the Minnesota Psychiatric Society partnered with the the Barbara Schneider Foundation and SAVE Minnesota in the wake of a national shooting incident to suggest alternatives.  Rather than speculate about psychiatric disorders or gun control we were focused on solutions that you can read through the link below.

The actual commentary was never published by the editor who apparently stated that there was a conflict of interest because we seemed to be fishing for research dollars.   It appears that the press can only hear the cycle of tragedy, speculation about mental health problems, and the need to move on.  The problem with that is that we continue to move on to another shooting.

George Dawson, MD


A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education