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

Death Cults

That may seem like an odd topic for a psychiatry blog but I did not know where to put this.  Earlier this week my wife and I decided to stop watching a popular television show called The Following.  It is basically a fictional show about a death cult that involves a charismatic psychopath who engages other psychopaths to do mass killing.  They typically use knives as murder weapons and kill large numbers of innocent people at public gatherings like book signings in book stores.  In one episode last year, the main psychopath in the show happened across the camp of another death cult run by a different psychopath and it was the expected lethal battle for leadership.  The dramatic tension is created by a group of FBI agents trying to catch and stop the psychopaths and the personal stories in that group.  In the opening show this year, there was a murder scene that was explained to the audience and then implicitly done that was so sadistic and so sick that we decided to shut off the show and never watch it again.

Violence and aggression are always in the background in America.  We take violence and aggression for granted and it seems surprising when they are excluded from entertainment.  What no car chases or shootings?  And it has been there a long time.  I can remember being in East Africa in the 1970s and at that time many of the Africans that I met, had the idea that most Americans carried guns.  That conclusion was from watching American films.  There has always been the debate about whether or not the display of all of this violence affects people.  Like practically all research of this type, I would expect the results to reflect the biases of the researchers.  Typical research would look at a large group  exposed and not exposed to violence in the media and the results are mixed.  Mixed results lead to the status quo, but the status quo has gradually gotten worse.  Television shows commonly have sadistic serial killers as their plot line and in one case a serial killer is the main character and hero.  

According to a 2012 report by the Media Violence Commission (1) major medical (including the American Psychiatric Association) and the major psychological organization in this country support the argument that there is a casual connection between media violence and aggressive behavior.  This report also looks at the biases that may be in place that might obscure that connection.  The authors mentioned the belief that the effects must be immediate and severe is a common bias.  In other words, I see a violent movie and perpetrate a violent act within the next day or two.  Instead over time, exposure may decrease prosocial behaviors.  This report briefly summarizes the literature on possible psychological mechanisms that occur with exposure to violence but the most important  conclusion is:

"One conclusion appears clear-extreme conclusions are to be avoided. Not every viewer or player will be affected noticeably, but from understanding the psychological processes involved, we know that every viewer or player is affected in some way."

Many clinical psychiatrists have talked with people who have perpetrated violence based on some act that was portrayed in the media.  These stories are also described in the media with some regularity.  I think that if there are any factors containing a media effect it is the moral development of most people and that fact that a lot of the violence is hypothetical and it could not be enacted without considerable resources.  Factors that may facilitate violence after exposure would include a developmentally immature brain or a brain that would be more susceptible to the priming effects of violence.  That would include various forms of severe mental illnesses or personality effects like psychopathy or antisocial personality disorder.  In many cases the perpetrators of violence has no idea about how devastating injuries can occur from fictional portrayals where people get up after being hit over the head with a pipe.  They don't realize that in many cases that results in a fatal or disabling brain injury.

The overriding dimension affecting violence that needs to be addressed is at the cultural level.  A critical recent development is the resurgence of the death cult.  The concept of death cult is poorly defined at this time and as far as I know there are no definitive scholars.  They seem to come in two forms.  The first requirement is a cult or an organization with a charismatic leader and followers who are willing to uncritically follow the edicts of the leader.  There have been various studies of the dynamics of these groups and who might be susceptible to becoming a cult member.  Jerrold Post, MD has analyzed the dynamics of charismatic leaders and describes them as "mirror hungry" personalities that require constant admiration, convey a sense of omnipotence and grandeur,  have the appearance of certainty, and rely heavily on splitting as an adaptive psychological defense (2).   Death cults seem to come down to 2 varieties - those predisposed to mass suicide and those that are predisposed to homicide and mass homicide or in some cases genocide.  For the purposes of this post, I am focused on the latter, because they seem to pose the most immediate danger to the most people.

Prototypical homicide focused cults or movements in my lifetime have included the Nazis and Pol Pot.  The concept of "charismatic leader" can probably extend to larger groups of extremists that have been described as being responsible for genocides (3).  Over the past 30 years, we have seen many of these cults or movements commit homicide to various degrees often with loose religious rationalizations.  The killings have become increasingly vicious and sadistic.  The killings have reached a level of intensity that all of the religious justifications no longer seem to apply.  The international solution has been to mobilize against these groups and in some cases, explicitly threaten to kill them.  The media is always complicit with death cult propaganda and the resulting desensitization may have been one of the factors in the escalation.  This is an interesting parallel with television entertainment that seems to be in the same cycle of escalating to the most horrifically sadistic and brutal types of killing and torture.

What is missing in all of this mass exposure to violence and killing is an explanation of the driving forces and a plan for change at a cultural level.  There is a current and shocking increase in antisemitism spreading across Europe, to the point that one author has suggested that it may be time for the Jews to leave Europe (4).  There don't seem to be any pacifists any more.  There is no peace movement like there was in the 1970s.   I have not seen any explanations for this primitive behavior and why it occurs even though many explanations have been around for years.  Here is one from Lifton that has been available since 1986 and it is accessible to any psychiatrist trained in psychodynamics or any good student of English literature:

"Fascist ideology can have particular appeal for the survivor self fighting off disintegration because it holds out, at all levels, a promise of unity, oneness, fusion.  It deals with death anxiety, moreover by glorifying death, even worshiping it.  While one's own death as a warrior is idealized, the self mostly escapes death - achieves the death of death - by killing others.  There can readily follow a vicious circle in which one kills, needs to go on killing to maintain one's cure, and seeks a continuous process of murderous, deathless, therapeutic survival.  One can then reach the state of requiring a sense of perpetual survival through the killing of others in order to re-experience endlessly what Elias Canetti has called the "moment of power" - that is the moment of cure."  p. 499.

Lifton knows full well that the fascist thought process that he describes is not a diagnosis,  but it is the way that large groups of people can think.  It has been present since the time of ancient man.  You can find theories about how it is "hardwired" into the human brain with suggestions that it is adaptive.  The only real way we can combat it is through educating people about what is really going on, improving critical thinking and changing popular culture.  Teach them how to recognize biases and overcome them.  A basic skill would seem to be able to recognize a death cult and realize why participation may not be in your best interest.  It goes without saying that it could not be in the best interest of civilized society, but the philosophy behind that probably needs teaching.

When I turned off my TV set the other day, I was not seeing it as a protest.  But if media producers realize that abhorrent violent content is less interesting that may be an important cultural change.      


George Dawson, MD, DFAPA




References:


1:  Media Violence Commission, International Society for Research on Aggression(ISRA). Report of the Media Violence Commission. Aggress Behav. 2012 Sep-Oct;38(5):335-41. doi: 10.1002/ab.21443. Epub 2012 Aug 10. Review. PubMed PMID: 22886500 (full text available online).

2:  Jerrold Post, MD.  Personality and Political Behavior.  Door County Summer Institute July 21-25, 2003.

3:  Alan J. Kuperman.  The Limits of Humanitarian Intervention - Genocide in Rwanda.  Brooking Institution Press.  Washington, DC (2001) p. 12.

4:  Jeffrey Goldberg.  Is It Time for the Jews to Leave Europe?  The Atlantic.  April 2015.

5:  Robert Jay Lifton.  The Nazi Doctors.  Basic Books, New York (1986) p. 499.




Supplementary 1:    I would not encourage anyone to watch the television program in question that I mention in paragraph 1.  I have seen plenty of media violence, but consider this depiction to be the worst.

Rampage Killing - The Public Health Approach Is Still Ignored

I was watching the news this morning on the latest rampage killing.  This news coverage features numerous replays of a YouTube video posted by the killer about twenty minutes before he started shooting.  I listened to an expert, (at least as much of an expert as you can be) talk about his approach to the problem.  He talked about the limitations of the post event "psychoanalysis" of the  killer and how a more functional approach would be to harden targets and warn the victims.  He talked about the false positive rate of how most people who threaten or post videos like this do not carry out the threatened violence making it impossible to detain all the people making the threats.  He said that it may be useful to talk to people with these problems but the psychology of this individual not only made that impossible, but even talking with mental health professionals was not likely to help him.

I had just finished reading the latest Psychiatric Annals.  This month's topic was Psychotic Rampage Killers.  Three of the four articles were written by C. Ray Lake, MD,  and the fourth by James l. Knoll, MD and J. Reid Meloy, PhD.  Dr. Lake also had an opinion piece on why mass murder diagnoses were justification for breaking the Goldwater Rule specifically the part ".... it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."  He points out that this rule is currently routinely broken with speculative diagnoses about psychotic mass killers.  He also suggests that the correct diagnosis is still an open question.  He also points out that the inadequate care of individuals with psychosis is an issue and that has been one of the themes of this blog.

Lake's main contention is that Psychotic Rampage Killers are really bipolar and manic and do not have schizophrenia.  He briefly reviews some of the facts including that even though a small percentage of killers (<10%) are psychotic, there are a distinct number of correlates that cause them to differ from non-psychotic killers most notably a motivation that is delusional in nature, the fact that they are always caught (as opposed to 33% of non-psychotic killers never being caught), warnings  and plans prior to the act are common, and half attempt or commit suicide.  The psychotic killer basically focuses on the event as a final stage and does not plan to escape or benefit from the event.  He makes the point that all of the psychotic killers realize that what they are doing is illegal and that can exclude an insanity defense if they survive.  I think this is also a common misconception on the part of the public.  People who are psychotic can carry out detailed plans that are consistent with the logic of their psychosis.  It certainly does not mean that they are rational.  He briefly reviews the issue of violence and psychosis and takes on the political issue that "violence perpetrated by mentally ill is no greater than violence carried out by the non-mentally ill population."  This has always been a statistical fallacy balancing the violence by a subgroup of the mentally ill against the violence of high risk members in the general population.  By now there should be no doubt that some people with severe mental illness have a much higher rate of violence than the general population.   Further there are known diagnostic features within that subgroup that are associated with the increased risk of violence including alcohol and drug addiction, paranoia, command hallucinations, and a lack of treatment.

Lake's initial discussion of prevention points out that gun legislation is not likely to be a solution because of existing biases by legislators in this area to do nothing despite the fact that most rampage killer use firearms and 75% of them were legally acquired.  Civil commitment laws were described as "limited by our sensitivity to personal freedoms."  In my experience, it comes down to the courts involved and the administrative element through the involved counties.  I have been personally involved in thousands of civil commitments and decisions by the courts often depend on the most recent "mistake" defined as an adverse outcome that occurred when a potentially violent person was released.  Certainly any case involving firearms and hundreds of rounds of ammunition or an actual shoot out with the police needs very close scrutiny.  Any "welfare check" by the police of a potentially dangerous person should involve a search for weapons and actual threats especially if they were posted on social media.  Mental health professional contact was described as being potentially useful but also limited by the nature of the follow up of patients with psychosis.  In fact, violence needs to be incorporated into the treatment  plan for patients with psychosis and violence and addressed in a comprehensive manner.  An appointment for a ten minute discussion of medications is not acceptable and it really is not an acceptable level of care for anyone with psychosis whether they are potentially violent or not.  Lake points out that there is also a call to avoid using the names and other materials posted by rampage killers.  I think that is a good idea and therefore do not refer to any of these materials here.

The discussion of what is the proper diagnosis of these murderers is the next article. Lake reviews the evidence (largely from media reports) and concludes that psychotic mania is the most likely diagnosis.  He has an interesting diagram in the article that shows both psychotic depression and psychotic mania converging on the diagnosis of "paranoid psychosis from mood disorders".  He also has interesting graphic using Venn diagram approaches that range from Kraepelin's initial clear distinction between bipolar disorder and schizophrenia to the more spectrum based approach beginning with Timothy Crow's continuum with schizophrenia and bipolar disorder being at opposite ends of the spectrum.  He expressed some surprise that schizoaffective disorder was still in the DSM-5, but it also considers Schizophrenia Spectrum and Other Psychotic Disorders separate from Bipolar and Related Disorders.  In reviewing the details from the media of five Rampage Killers, he concludes that in all cases psychotic mania was a diagnostic consideration based on hyperactivity, insomnia, and delusional thinking.  In one case there was a family history of bipolar disorder.

Lake goes on to point out that without an accurate diagnosis of bipolar disorder, patients do not receive standard of care which he defines as mood-stabilizing drugs.  He digresses to talk about the legal profession changing the diagnostic habits of professional and uses false memory syndrome as a case in point.  He goes on to suggest that "Successful legal action in the form of a class action lawsuit filed on behalf of unrecognized bipolar disorder misdiagnosed with and mistreated for schizophrenia could quickly change psychiatric diagnostic practices.  Another potential class action lawsuit is possible from some of the mass murder victims families in cases where before the rampage, the psychotic murderer had been treated for schizophrenia and not bipolar disorder."  Dr. Lake considers the problem basically to be one of "obsolete diagnostic concepts that promote substandard medical care for psychotic patients."

In 30 years of practice, I have not made the same observations that Dr. Lake has made.  In the example of false memory syndrome, that diagnosis and the associated multiple personality disorder phenomena was really practiced by a small minority of psychiatrists.  It was actively criticized at the time by prominent psychiatrists in prominent journals.  I  doubt that lawsuits against anyone had any impact on the diagnostic concepts of the vast majority of psychiatrists.  On the issue of diagnosing bipolar disorder based on a spectrum concept and the features of hyperactivity and insomnia. I would suggest that is fraught with problems.  Having seen patients over time patients with schizophrenia can also have these features. The same problems occur when considering standard of care arguments for mood stabilizers.  All of them (lithium, divalproex, lamotrigine) have significant problems with both efficacy and side effects profiles.  Antipsychotic medication is probably necessary in at least 50% of bipolar patients (in addition to the mood stabilizer), and many antipsychotics are FDA approved for acute bipolar disorder and bipolar depression.  But the larger problem is that there needs to be a standard of care than encompasses much more than medication.  That is good for all patients with psychosis and potentially very good for those at risk for violence.

The recommendations I have discussed before on this blog that I think will have the most impact would be:

1.  Establish centers of excellence for treating psychotic disorders.  We know the outcome of rationing mental health services.  We end up with inadequate inpatient and outpatient care for patients with psychosis and bipolar disorder.  The focus of all for profit systems is to transfer the cost of care for these individuals to public systems including correctional facilities.  If they end up being cared for in a for profit system, the care is concentrated on their ability to see a physician or more appropriately a "prescriber" for about 10-20 minutes and accurately describe their problems.  It is well known that psychotic rampage killers do not consider their homicidal ideation to be a problem and may actively try to hide those thoughts from any interviewer.

2.  A standardized approach to law enforcement intervention.  Law enforcement has a number of possible interventions available to them that are not available to mental health professionals.  The duty to warn legislation has blurred these distinctions and essentially removed a lot of responsibility from law enforcement.  There is really no reason why a person posting obvious threats on the Internet should not be treated with the same degree of caution as perpetrators of domestic violence.  That would include proscriptions against owning and acquiring firearms, police surveillance and where necessary orders for protection.  Threats to kill should trigger a response that involves a search for firearms and materials showing a plan to perpetrate violence.

3.  A public health approach focused on the issue of homicidal ideation as a potential symptom of mental illness.  The public and the patients themselves need to be able to conceptualize this problem as an illness and a symptom that does not need to be acted upon.  The article reference here refer to outdated diagnostic concepts and I would include the idea that patients with psychosis especially delusions cannot modify their thinking by means other than medication.  It certainly happens in response to events but also as a result of psychotherapy.

4.  Comprehensive outpatient care.  Brief checks focused on medications are doomed to fail.  These patients and all patients with psychoses need comprehensive outpatient care that includes home visits when necessary, psychotherapy, comprehensive cognitive assessments, and vocational rehabilitation.  When I first started working these were all available in my clinic.  Today it is unheard of.

Psychosis and psychotic people who kill are the psychiatric equivalent of a heart attack.  Any middle aged person in the country with chest pain gets admitted and goes through about 24 hours of comprehensive testing and imaging.  I don't know the actual statistics but I would guess that most of these people are not having heart attacks and their hospital and Cardiology bill is about $30,000 - $50,000.  Our system of care expects a person with psychosis who is totally unaware of the fact that they have a significant disturbance in their thinking to want to actively manage that illness on resources that are trivial in comparison.  In the case of an identified heart attack, that person will receive hundreds of thousands of dollars of additional care.  By comparison a person receiving the most comprehensive level of community care - Assertive Community Treatment or ACT receives those services for about $10,000 per year.  That service is typically limited to a few hundred people in each state and not covered by medical insurance.

The best approach to rampage killers is to offer a much better standard of care to all people with psychosis.  If it the right thing to do from the perspective of psychiatry, public health, and humanism.

George Dawson, MD, DFAPA

Lake CR.  Rampage murders, Part I: Psychotic versus non-psychotic and a role for psychiatry in prevention.  Psychiatric Annals 2104 (44) 5: 216-225.

Lake CR.  Psychotic rampage murders, Part II: Psychotic mania, not schizophrenia.  Psychiatric Annals 2104 (44) 5: 216-225.

Supplementary 1:

"Charges for chest pain, for instance, rose 10 percent to an average of $18,505 in 2012, from $16,815 in 2011. Average hospital charges for digestive disorders climbed 8.5 percent to nearly $22,000, from $20,278 in 2011."

J Creswell, S Fink, S Cohen.  Hospital Charges Surge for Common Ailments, Data Shows.  New York Times; June 2, 2014.

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

The Duty to Warn, Law Enforcement and the Public Health

The issue of reporting dangerousness to law enforcement was in the news this week with a story 2 days ago about the accused Colorado theater shooter James Holmes.  I happened to catch it on public radio where it was announced that NPR had been one of the news organizations who had petitioned the court for access to suppressed information about the psychiatrist’s role.  The New York Times story states that the psychiatrist – Dr. Lynne Fenton contacted campus police about Holmes' potential dangerousness and they deactivated his student ID and access to campus building.  Various sources state that he was threatening his psychiatrist by e-mail.  The new information is more detailed than an original article from the Denver Post on August 30, 2012.

In the original article Dr. Fenton testified that her physician-patient relationship with the patient ended on June 11.  At that appointment there are some reports that Holmes told Dr. Fenton that he fantasized about killing a lot of people.  The shooting occurred on July 20.   The newly unsealed documents show that the psychiatrist “told a police officer that her patient had confessed homicidal thoughts and was a danger to the public.”  The documents also show that the psychiatrist was being threatened by both e-mails and texts.  Dr. Fenton also advised the police officer that she was fulfilling her legal requirement by making the report to the police.  A related article states that police officer asked Dr. Fenton if she wanted the subject apprehended and placed on a 72 hour hold and she said that she did not.

In addition to the public health concern about homicide prevention, psychiatrists in this situation have a concern about the need to prevent their patients from harming others.  That forms the basis of at least one dimension of most state civil commitment laws.  Most state laws describe a duty to warn potential victims, but forensic psychiatry texts talk about more general responsibilities.  For example, Gutheil and Appelbaum state:

“Psychiatrists have always faced the potential of suits as a result of negligently allowing patients to be released or to escape from inpatient facilities when these patients later cause harm to others…” (p. 148)

In a typical outpatient setting, the modern duty to protect identifiable persons dates back to the Tarasoff case or Tarasoff v. Regents of the University of California.  In this case a psychologist was informed by his patient that he intended to kill a young woman.  The psychologist contacted campus police and advised them that the patient had schizophrenia and should be detained and committed.  The police temporarily detained the subject but he was released and several months later and killed the identified victim.   The courts found that there was a duty to warn the identified victim that superseded confidentiality.  I encourage anyone to read the details of the original review of the case to notice how negligence in this case passes from the mental health professionals to the police and back.  I think that there may be a more straightforward analysis and I would invite any evidence to the contrary.  My understanding is that the legal profession studies negligence from the perspective that there is no one who is free from responsibility.  In any complex activity like needing to report dangerousness, there will always be some sharing of responsibility if there is a bad outcome.  From a physicians perspective the probability of that happening increases with the presence of liability insurance.

On a personal level, occupational stress goes through the roof in situations like this.  Imagine that you are seeing patients in a clinic and trying to be as helpful as possible and you have just seen a person who you think is dangerous.  The situations is more complex if that patient has threatened a specific person, threatened you and your family, or brought a weapon into the clinic.  The first order of business is to try and calm down.  In some cases you may have colleagues available for consultation, but in many cases a psychiatrist is on their own.  The next step is figuring out whether you are in a situation that requires a duty to warn and what must be done to fulfill that obligation.  State statutes are complicated and not uniform.  In a recent review of state Tarasoff laws, the statutes of all 50 states and the District of Columbia were categorized into whether or not reporting was mandatory, discretionary, or no law at all. The definition of mandatory for this classification was a requirement to warn.  Discretionary allows for a breach of patient or client privileges for the purpose of warning.  Using this analysis 33 states have a mandatory duty, 11 states are discretionary and 7 states have no law.  Psychiatrists at this point may seek legal consultation due to the complexity of the situation and may still receive vague advice.  A good example is something along the lines of: “Well I would rather defend you for this rather than that.” – based on their preceding legal advice.  The first time I bumped up against that advice I realized that doctors were cannon fodder for the legal profession. 

The second critical point is the call to the police.  In both of the cases mentioned so far campus police were involved.  Are there courts where that would be questioned?  I don’t think that duty to warn laws specify any particular law enforcement.  Despite that lack of specificity, the police have widely variable capacities to respond to these calls.  The police can be notified and nothing can happen.  As illustrated in this post, the police can be notified and decide on their own that the patient is not dangerous and release them.  That also applies to what type of protection the police can offer potential victims.  I have seen the police go directly to a the person issuing the threats and tell them there will be clear legal problems if they do not stop to mailing a fax of a handgun receipt of transaction where the potential perpetrator who had already issued threats had acquired a handgun.  There is often a significant gap between any report to the police and palpable decrease in danger to those threatened.  In many cases an entire clinic is threatened and a safety plan needs to be put in place.  

The final consideration is whether the person needs an acute evaluation and emergency hospitalization for psychiatric assessment.  I have several previous posts giving my perspective on the issue of homicide prevention and how acute psychiatric treatment can prevent aggression and violence, but it takes a functional commitment court and facilities that have the expertise to provide this level of treatment.  Many decisions seem to be made based on existing resources rather than any absolute quality marker.  Should any person who is homicidal because of an acute psychiatric disorder not be hospitalized because the local community hospital does not treat aggressive individuals?  Should that decision be made on a decision by Medicare or the managed care industry on how many days of hospital care they will pay for?  Hospitalizations for these patients typically outrun the funding by 2 – 3 weeks.

Like all of the piecemeal approaches to involuntary treatment there is an easy fix.  I did not digress into the tremendous amount of stress these situations cause and how that stress can drag on for weeks to months.  If there is an adverse outcome the stress level is even worse.  What is needed is a clear pathway that maintains the boundary between law enforcement and psychiatry.  A uniform law implemented across the country should clearly say that a psychiatrist has a duty to report to law enforcement and at that point law enforcement has a duty to assess and potentially detain the person making the threat.  That would include transporting them to a hospital that does civil commitments for emergency treatment as necessary.  Law enforcement also needs to warn the potential victim and protect them.  Psychiatrists should have no duty to track down identified victims or apprehend or take threatening patients into custody.  That is clearly the purview of law enforcement.

The technical details of the interface between the law and psychiatry in the case of a threatening or potentially violent patient needs a great deal of improvement.  There are very few situations as stressful in the rest of medicine.  Some psychiatrists will encounter these situations only a few times in their career and others are immersed in aggression and violence.  Improving the approach will enhance assessment and treatment of the problem and also make it easier to recruit talented people to focus on the problem.

George Dawson, MD, DFAPA

Edwards, Griffin Sims, Database of State Tarasoff Laws (February 11, 2010). Available at SSRN: http://ssrn.com/abstract=1551505 or http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1551505

Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law.  Lippincott, Williams & Wilkins.  Phialdelphia (2000): p  148

What is wrong with the APA's press release about the NRA statement?

The APA released a statement about the NRA's comments, probably Mr. LaPierre's statements on Meet the Press on Sunday and a separate NRA release. There are several problems with the APA statement:

1.   The American Psychiatric Association expressed disappointment today in the comments from Wayne LaPierre…

Why would the APA be "disappointed" in a predictable statement from a gun lobbyist?  I really found nothing surprising in Mr. LaPierre's presentation or the specific content. As I previously posted, the NRA predictably sees guns as the solution to gun violence.  The concept "more guns less crime" has been a driving force behind their nationwide campaign for concealed carry laws. The concealed weapons that are being carried are handguns and handguns are responsible for the largest percentage of gun homicides in the United States. It is probably a good idea to come up with a solution rather than reacting to a predictable statement.

2.  The person involved in the shooting is named…

Although it is controversial, there is some evidence that media coverage is one factor that can lead predispose individuals to copy a particular crime.  Although this press release is a minimal amount of information relative to other news coverage, it does represent an opportunity for modeling techniques for more appropriate media coverage and that might include anonymity of the perpetrator.  The NRA release makes the same mistake.

3.   In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are “so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,” a description that leads to the further stigmatization of people with mental illnesses.

It is always difficult to tell how rhetorical a person is being when they use terms like "evil" and "demons". If they are considered to be descriptive terms for a supernatural force that suggests an etiology of mental illness that was popular in the Dark Ages.  Evil on the other hand does have a more generic definition of "morally wrong or bad;  immoral; wicked”.  In this case it is important to know if the speaker is referring to a definition that is based on evil as a supernatural force or a more common description. This is another educational point. People who experience voices and irrational thoughts involving homicide can be understood. Psychiatrists can understand them and can help them to come up with a plan to avoid acting on those thoughts and impulses and getting rid of them.  The NRA release is basically an indication of a high degree of naïveté in thinking about the unique conscious state of individuals.  The APA release should correct that.

4.  The APA notes that people with mental illnesses are rarely violent and that they are far more likely to be the victims of crimes than the perpetrators

The actual numbers here are irrelevant.  Psychiatric epidemiology cannot be casually understood and the media generally has the population whipped up about the notion of psychiatric overdiagnosis of everything anyway. The idea that some mentally ill persons are dangerous is common sense and forms the basis of civil commitment and emergency detention laws in every state of the union. Advocates need to step away from the notion that recognizing this fact is "stigmatizing". The APA needs to recognize that their members in acute care settings are dealing with this problem every day and need support. It is an undeniable fact that some persons with mental illness are dangerous and it is an undeniable fact that most of the dangerous people do not have mental illness. Trying to parse that sentence usually results in inertia that prevents any progress toward solutions.

The APA seems to have missed a golden opportunity to suggest a plan to address the current problem. The problem will not be addressed by responding to predictable NRA rhetoric.  There several other nonstarters in terms of a productive dialogue on this issue including - the specifics of the Second Amendment and specific gun control regulations. The moderator of Meet The Press made an excellent point in the interview on Sunday when he asked about closing the loophole that 40% of gun purchases occur at gun shows where there are no background checks. It was clear that the NRA was not interested in closing that loophole. The main problem is that the APA has no standing in that argument. Second nonstarter is the whole issue of predictability. Any news outlet can find a psychiatrist somewhere who will comment that psychiatrists cannot predict anything. That usually ends the story. If your cardiologist cannot predict when you will have a heart attack, why would anyone think that a psychiatrist could predict a rare event happening in a much more complicated organ? Psychiatrists need to be focused on public health interventions to reduce the incidence of violence and aggression in the general population and where it is associated with psychiatric disorders. 

What about Mr. LaPierre’s criticism of the mental health system?

“They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine.  We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this…”

Is it an accurate global description of what has happened to the mental health system in this country? He certainly is not using the language of a mental health professional or a person with any sensitivity toward people with mental illness.  There are numerous pages on this blog documenting how the mental health system has been decimated over the past 25 years and some of the factors responsible for that. Just yesterday I was advised of a school social worker who not only was unable to get a child hospitalized but could not get them an outpatient appointment to see a psychiatrist. The government and the managed care industry have spent 25 years denying people access to mental health care and psychiatrists. They have also spent 25 years denying people access to quality mental health care that psychiatrists are trained to provide. We have minimal infrastructure to help people with the most severe forms of illness and many hospital inpatient units do discharge people to the street even though they are unchanged since they were admitted.   Any serious dialogue about the mental health aspects of aggression and violence needs to address that problem.

That is where the APA’s voice should be the loudest.

George Dawson, MD, DFAPA

Supplementary Material:  Quotes from and locations of transcripts – feel free to double check my work.

MTP transcript  12/23:  http://www.msnbc.msn.com/id/50283245/ns/meet_the_press-transcripts/t/december-wayne-lapierre-chuck-schumer-lindsey-graham-jason-chaffetz-harold-ford-jr-andrea-mitchell-chuck-todd/#.UNlaJ-RqYrV

"I'm telling you what I think will make people safe. And what every mom and dad will make them feel better when they drop their kid off at school in January, is if we have a police officer in that school, a good guy, that if some horrible monster tries to do something, they'll be there to protect them." (p2)

"Look at the facts at Columbine. They've changed every police procedure since Columbine. I mean I don't understand why you can't, just for a minute, imagine that when that horrible monster tried to shoot his way into Sandy Hook School, that if a good guy with a gun had been there, he might have been able to stop..."—(p3)

"There are so many different ways he could have done it. And there's an endless amount of ways a monster.."—(p6)

"I don't think it will. I keep saying it, and you just won't accept it. It's not going to work. It hasn't worked. Dianne Feinstein had her ban, and Columbine occurred. It's not going to work. I'll tell you what would work. We have a mental health system in this country that has completely and totally collapsed. We have no national database of these lunatics." (p6)

"23 states, my (UNINTEL) however long ago was Virginia Tech? 23 states are still putting only a small number of records into the system. And a lot of states are putting none. So, when they go through the national instant check system, and they go to try to screen out one of those lunatics, the (p6)

"I talked to a police officer the other day. He said, "Wayne," he said, "let me tell you this. Every police officer walking the street knows s lunatic that's out there, some mentally disturbed person that ought to be in an institution, is out walking the street because they dealt with the institutional side. They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine."We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this"—(p7)

NRA transcript 12/21: http://home.nra.org/pdf/Transcript_PDF.pdf

"The truth is that our society is populated by an unknown number of genuine monsters — people so deranged, so evil, so possessed by voices and driven by demons that no sane person can possibly ever

comprehend them." (p2)

"Yet when it comes to the most beloved, innocent and vulnerable members of the American family — our children — we as a society leave them utterly defenseless, and the monsters and predators of this world know it and exploit it. That must change now!" (p2)

"As parents, we do everything we can to keep our children safe. It is now time for us to assume responsibility for their safety at school.  The only way to stop a monster from killing our kids is to be personally involved and invested in a plan of absolute protection. The only thing that stops a bad guy with a gun is a good guy with a gun. Would you rather have your 911 call bring a good guy with a gun from a mile away ... or a minute away?" (p5)

"Now, I can imagine the shocking headlines you'll print tomorrow morning: "More guns," you'll claim, "are the NRA's answer to everything!" Your implication will be that guns are evil and have no  place in society, much less in our schools. But since when did the word "gun" automatically become a bad word?" (p5)

"Is the press and political class here in Washington so consumed by fear and hatred of the NRA and America’s gun owners that you're willing to accept a world where real resistance to evil monsters is a lone, unarmed school principal left to surrender her life to shield the children in her care?" (p6)

Additional Reference:

Copycat Phenomenon in medical literature (references 5, 13, 20, 26 are most relevant).

Guns Are Not Cooling Off Between Mass Shootings

I have previously posted my concerns about mass shootings and the general paralysis on dealing with this problem.  The gun lobby has unquestionable political power on this issue, but that is also due to judicial interpretation of the Second Amendment as it is written.  Today's New York Times describes a mass shooting at an elementary school in Connecticut.  At the time I am typing this, the death toll is 20 children, 6 adults, and the gunman.  This incident occurs three days after a shopping mall shooting in Oregon.

Most people would think that nothing would be more motivating for major societal changes than children being attacked in this manner.  Unfortunately this is not the first time that children have been victimized by mass shooters.  On October 2, 2006 a gunman shot 10 girls and killed 5 before committing suicide.  According to the Wikipedia article that was the third school shooting that week.  Altogether there have been 31 school shootings since the Columbine incident on April 20, 1999.

My question and the question I have been asking for the past decade is what positive steps are going to be taken to resolve this problem?  How many more lives need to be lost?  How many more children need to be shot while they are attending school?  Some may consider these questions to be provocative, but given the dearth of action and the excuses we hear from public health officials and politicians, I am left in the position of continuing to sound an alarm that should have been heard a couple of decades ago.  After all, the elections are over.  The major parties don't have to worry about alienating the pro-gun or the pro-gun control lobbyists and activists.  This will not be solved as a Second Amendment or political issue.  I have said it before and I will say it again - the basic approach to the problem is a scientific one and a proactive public health one that involves the following sequence of action:

1.  Get the message out that homicidal thoughts - especially thoughts that involve random violence toward strangers are abnormal and treatable.  The public health message should include what to do when the thoughts have been identified.

2.  Provide explanations for changes in thought patterns that lead to homicidal thinking.

3.  Provide a discussion of the emotional, personal and economic costs of this kind of violence.

4.  Emphasize that the precursors to homicidal thinking are generally treatable and provide accessible treatment options and interventions.

5.  The cultural symbol of the lone gunman in our society is a mythical figure that needs to go.  There needs to be a lot of work done on dispelling that myth.  I don't think that this repetitive behavior by individuals with a probable psychosis is an accident.  Delusions do not occur in a vacuum and if there is a mythical explanation out there for righting the wrongs of a delusional person - someone will incorporate it into their belief system.  The lone gunman is a grandiose and delusional solution for too many people.  If I am right it will affect even more.

6.  Study that sequence of events and outcomes locally to figure out what modifications are best in specific areas.

One of the main problems here may be the deterioration in psychiatric services over the past three decades largely as a result of government and managed care manipulations.  Ironically being a danger to yourself or others is considered the main reason for being in an inpatient psychiatric unit these days.  I wonder how much of the inertia in dealing with the problem of mass homicide comes from the same forces that want to restrict access to psychiatric care?  Setting up the remaining inpatient units to deal with a part of this problem would require more resources for infrastructure, staff training, and to recruit the expertise needed to make a difference.

The bottom line here is that the mass homicide epidemic will only be solved by public health measures.  This is not a question of good versus evil.  This is not a question of accepting this as a problem that cannot be solved, grieving, and moving on.  This is a question of identifiable thought patterns changing and leading to homicidal behavior and intervening at that level.

George Dawson, MD, DFAPA

More On Homicide Prevention

As the number of mass homicides becomes even more noticeable it is getting some attention in the psychiatric press. This months Psychiatric News has a story that looks at the issue of "explanations" for mass killings. There were a couple of new terms that I was not familiar with such as "rampage violence" or "rampage", "autogenic", or "pseudo-commando" killings.  The perspective in the article was generally public health research or the perspective of forensic psychiatrists. Inconsistencies were apparent such as:

"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."

Followed by:

"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."

Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".

The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph.  Like most things political in the US, all you have to do is follow the money.

The same issue was covered in the September issue of Psychiatric Times.  Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed.  He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi.  Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:

"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."

and

"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo.  The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."

He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.

I don't think that gun laws are the best or only approach.  The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal.  Anyone armed with those weapons alone would be unstoppable in a mass shooting situation.  Secondly, the effects of stringent firearms laws have mixed results.  The mass shooting in Norway is an example of how tight firearm regulation can be circumvented.  It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely.  There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US.  Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.

The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control.  That is also consistent with a humanistic approach to the problem.  I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work.  We need a culture that is much more savvy about the origins of violence and aggression.  It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach.  Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.

George Dawson, MD, DFAPA

Aaron Levin.  Experts again seek explanations for mass killings.  Psychiatric News 2012 (47)17: 1,20.

Lloyd I. Sederer.  The enemy is apathy.  Psychiatric Times 2012 (29)9: 1-2.

Allen Frances.  Mass murderers, madness, and gun control.  Psychiatric Times 2012 (29)9:1-2.

Violence Prevention - Is The Scientific Community Finally Getting It?

I have been an advocate for violence prevention including mass homicides and mass shootings for many years now.  It has involved swimming upstream against politicians and the public in general who seem to believe that violence prevention is not possible.  A large part of that attitude is secondary to politics involved with the Second Amendment and a strong lobby from firearm advocates.  My position has been that you can study the problem scientifically and come up with solutions independent of the firearms issue based on the experience of psychiatrists who routinely treat people who are potentially violent and aggressive.

I was very interested to see the editorial in this week's Nature advocating the scientific study of mass homicides and firearm violence. They make the interesting observation that one media story referred to one of the recent perpetrators as being supported by the United States National Institutes of Health and somehow implicating that agency in the shooting spree and that:

"In this climate, discussions of the multiple murders sounded all too often like descriptions of the random and inevitable carnage caused by a tornado or earthquake".

Even more interesting is the fact that the National Rifle Association began a successful campaign to squash any scientific efforts to study the problem in 1996 when it shut down a gun violence research effort by the Centers for Disease Control and Prevention. The authors go on to list two New England Journal of Medicine studies from that group that showed a 2.7 fold greater risk of homicide in people living in homes where there was a firearm and a 4.8 fold greater risk of suicide.  Even worse:

 "Congress has included in annual spending laws the stipulation that none of the CDC's injury prevention funds "may be used to advocate or promote gun control"."

This year the ban was extended to all agencies of the Department of Health and Human Services including the NIH.   There is nothing like a gag order on science based on political ideology. 

The authors conclude by saying that rational decisions on firearms cannot occur in a "scientific vacuum".   That is certainly accurate from both a psychiatric perspective and the firearms licensing and registration perspective. Based on their responses to the most recent incidents it should be clear that politicians are not thoughtful about this problem and they certainly have no solutions. We are well past time to study this problem scientifically and start to design approaches to make mass shootings a problem of the past rather than a frequently recurring problem.

George Dawson, MD, DFAPA

Who calls the shots? Nature. 2012 Aug 9;488(7410):129. doi: 10.1038/488129a. PubMed PMID: 22874927.

"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

Colorado Mass Shooting Day 2

I have been watching the media coverage of the mass shooting incident today - Interviews of family members, medical personnel and officials.  I saw a trauma surgeon at one of the receiving hospitals describe the current status of patients taken to his hospital.  He described this as a "mass casualty incident".  One reporter said that people don’t want insanity to replace evil as a focus of the prosecution.

In an interview that I think surprised the interviewer, a family member talked about the significant impact on her family.  When asked about how she would "get her head around this" she calmly explained that there are obvious problems when a person can acquire this amount of firearms, ammunition, and explosives in a short period of time.  She went on to add that she works in a school and is also aware of the fact that there are many children with psychological problems who never get adequate help.  She thought a lot of that problem was a lack of adequate financing. 

   

I have not listened to any right wing talk radio today, but from the other side of the aisle the New York Times headline this morning was "Gunman Kills 12 in Colorado, Reviving Gun Debate."  Mayor Bloomberg is quoted: “Maybe it’s time that the two people who want to be president of the United States stand up and tell us what they are going to do about it,” Mr. Bloomberg said during his weekly radio program, “because this is obviously a problem across the country.”

How did the Presidential candidates respond?  They both pulled down the campaign ads and apparently put the attack ads on hold.   From the President today: " And if there’s anything to take away from this tragedy, it’s a reminder that life is fragile.  Our time here is limited and it is precious.  And what matters in the end are not the small and trivial things which often consume our lives.  It’s how we choose to treat one another, and love one another.  It’s what we do on a daily basis to give our lives meaning and to give our lives purpose.  That’s what matters.  That’s why we’re here."   A similar excerpt from Mitt Romney: "There will be justice for those responsible, but that’s another matter for another day. Today is a moment to grieve and to remember, to reach out and to help, to appreciate our blessings in life. Each one of us will hold our kids a little closer, linger a bit longer with a colleague or a neighbor, reach out to a family member or friend. We’ll all spend a little less time thinking about the worries of our day and more time wondering about how to help those who are in need of compassion most."

These are the messages that we usually hear from politicians in response to mass shooting incidents.  At this point these messages are necessary, but the transition from this incident is as important.  After the messages of condolences, shared grief, and imminent justice that is usually all that happens.  Will either candidate respond to Mayor Bloomberg's challenge?  Based on the accumulated history to date it is doubtful.
  
A larger question is whether anything can be done apart from the reduced access to firearms argument.  In other words, is there an approach to directly intervene with people who develop homicidal ideation?  Popular consensus says no, but I think that it is much more likely than the repeal of the Second Amendment.

George Dawson, MD, DFAPA

Barack Obama. Remarks  by the President on the Shootings in Aurora Colorado.  July 20, 2012

Barack Obama.  Weekly Address: Remembering the Victims of the Aurora Colorado Shooting.  July 21, 2012.

Mitt Romney.  Remarks by Mitt Romney on the Shooting in Aurora, Colorado.  NYTimes July 20, 2012. 

Mass shootings - How Many Will Be Tolerated?

I have been asking myself that question repeatedly for the past several decades.  I summarized the problem a couple of months ago in this blog.  In the 12 hour aftermath of the incident in Aurora, Colorado I have already seen the predictable patterns.  Condolences from the President and the First Lady.  Right wing talk radio focused on gun rights and how the liberals will predictably want to restrict access to high capacity firearms.  Those same radio personalities talking about how you can never predict when these events will happen.  They just do and they cannot be prevented. One major network encouraging viewers to tune in for more details on the "Batman Massacre." 

We can expect more of the same over the next days to weeks and I will not expect any new solutions.  Mass shootings are devastating for the families involved.  They are also significant public health problems.  There is a body of knowledge out there that has not been applied to prevent these incidents and these incidents have not been systematically studied.  The principles in the commentary statement listed below still apply.  

It is time to stop acting like this is a problem that cannot be solved.

George Dawson, MD, DFAPA

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

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.