Slow Burn- Cho Seung-Hui-Differential Diagnosis

Yesterday I saw the morning news and posted all those questions, knowing full well that much would come to surface in the coming days. It didn't stop me, all day long, from forming an opinion.

I saw kids doing that on television, forming opinions, and I've read blogs with opinions. I mostly heard words like "evil" and "sociopath."

After 2 hours of ABC News (who can resist Diane Sawyer?)and spontaneous tears through the footage of kids hugging and crying, and those pictures of the dead, the young, the beautiful, the talented, I still hadn't heard from the therapy docs.

There was one forensic psychiatrist on t.v., a great looking guy with a really convincing manner, very animated and right-on in some respects, for sure. He said that Cho had contempt, vicious contempt and conceit, and was filled with hatred towards the people who had hurt him.

So knowing that, I feel you need more about Cho's condition. "Contempt" hardly cuts it for me as a diagnosis.

If he was paranoid, he either had a personality disorder, perhaps Paranoid Personality Disorder, or a biological axis I disorder such as Schizophrenia, Paranoid Type.

But that's all too easy, because there are premorbid disorders, conditions people have prior to the onset of say, a psychotic disorder like Schizophrenia Paranoid Type, 295.30. And generally, people with that disorder do not function throughout childhood to the degree that we think he functioned (although at this writing, we really don't have the details about his childhood).

You notice that nowhere am I using words like evil or sociopath. That's because they aren't diagnoses. Sociopathy is a symptom of Antisocial Personality Disorder, but I haven't read anything to indicate that Cho had that. He was considered quiet and detached, not openly defiant through out his life.

Until April 16, 2007, when he defied very openly.

That can happen if a person is hearing voices (delusions) that tell him to do that, to kill people (Schizophrenia, Paranoid Type).

It surely happens when people are psychotically depressed, meaning they are suffering from a mood disorder and they want to die and are at the point of suicide, but their anger (I told you it's bad to be angry) gets the better of them. Add to that the energy (a sequela to anger) to take everyone down with them.

The ticking time bomb thing. They noticed that on campus.

According to his friends, Cho had an imaginary girlfriend. He stalked 2-3 female students, and he told his roommates about a rejection, "I might as well kill myself."
The police say he didn't threaten the women he stalked, meaning he was obsessed with them, a feature of Borderline Personality Disorder and several anxiety disorders. He didn't go home for winter or spring break (detached socially). He slept with the lights on (anxious). He may have had voices speaking to him in the dark.

Here's what I think was going on, and maybe we'll find I'm wrong in a couple of hours (it's still good to go over the different possibilities for your edification).

I think Cho had a Social Phobia and a Schizoid Personality Disorder (DSM IV-TR 301.20) that was premorbid for either Schizophrenia Paranoid Type, or Mood Disorder with Psychotic Features (psychotic = murderous), the primary DX that he had before and during his very violent outburst. Schizoid Personality Disorder looks like this, credit to the DSM:

A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
(1) neither desires, nor enjoys close relationships, including family
(2) almost always chooses solitary activities
(3) has little, if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or confidants other than first-degree relatives
(6) appears indifferent to the praise or criticism of others.
(7) shows emotional coldness, detachment, or flattened affectivity

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder, or another medical condition.

Schizoid Personality Disorder is found premorbid to schizophrenia.

Anyway. If I think he either he always suffered from schizophrenia but he was highly functional, or

H was an abused person, abused from early childhood, either physically, verbally, emotionally or sexually. Or he lived with someone who beat or abused someone else, perhaps a sibling or a parent.

He developed severe, severe anxiety and a Social Phobia, and more damage, damage to the psyche and to the personality.

The personality is paralyzed in schizoid individuals and Cho didn't talk to people. He did speak through his plays, and he undoubtedly (in my guess-tim-ation) talked to himself about his anger at people who teased him for his inability to spit out words, and his anger at people for being rich, beautiful, whatever. He was his only friend.

One student at VTech said that they used to play games with Cho. "I'll give you ten dollars if you'll say, 'gimme five'."

That makes a shy person angry. It builds up. It's likely it went on throughout his childhood, derision for being socially unskilled, "weird." Socially detached people aren't understood by others, they're teased. But they have feelings and get angry. It can simmer through the years. The anxiety turns to anger. They're both symptoms of arousal.

That kind of psychotic anger is typical in Schizophrenia, Paranoid Type, too. We feel that stress triggers the genetic predisposition to schizophrenia. The stress of needing female companionship, the stress of grades, the stress of comparative poverty--these are triggers. People with schizophrenia are very sensitive. You don't want to upset them, criticize them (expressed emotion, discussed elsewhere in this blog). This is why I keep stressing Be Nice. We do have a societal obligation, among other things, to be nice. His room mates, by the way, are amazingly wonderful people. They were so patient with this boy who was so ill.

The therapy doc he saw didn't recognize the arousal, the potential for harm, because Cho was probably mute. He looked anxious, probably depressed. They'd call it "agitated depression" perhaps.

People did see him seething, however, and one teacher threatened to quit if he wasn't removed from his class, so he was clearly out of control of his emotions. He needed what we would call, Major Meds.

He was psychotic, of that there's not doubt, regardless the cause, and his teachers DID call the police, and students DID treat him with kid gloves. (Go to the CNN website and see that video with his roommates on 360.)

Sure, 20/20 hindsight, he needed to be forcibly hospitalized and treated. I won't hold by evil, or by sociopath, cold-blooded killer ala Sopranos.

The guy was mentally ill.

I have to go watch t.v.

P.S. I'm adding this to the post later. I chose schizoid personality disorder over childhood schizophrenia based upon his high functioning in academics, but indeed, his poor functioning socially, and perhaps inability to relate to anyone, including a therapist, might have indicated childhood schizophrenia. For all we know he was delusional all of his life, and it's possible that he had many incoherent, mind-jumbled days during his childhood.

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