Another diagnosis heard from: more Cho

Jeffrey Kluger, in this week's issue of TIME MAGAZINE interviewed several forensic psychiatrists and proceeded to propose a theory about Cho's psychology not much different than the one I did on Slow Burn, except that he adds a feature I left out. Narcissism.

It's worth a look as it adds another plausible diagnosis to the soup. Cho fit the features of the disorder, listed below.

Narcissistic Personality Disorder, 301.81.

The DSM IV-TR:

A pervasive pattern of grandiosity (in fantasy and behavior), need for admiration, and lack of empathy, beginning by early childhood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) shows arrogant, haughty behaviors or attitudes

Although it may look like a match, based on the video, keep in mind that people with Narcissistic Personality Disorder (NPD) usually aren't mute. They interact socially with people who respect and flatter them, and can be as physically attractive as anyone else, so they have something of a social network, although it's usually small and the turn-over is high. They're not real likable, despite thinking they should be.

Cho never interacted with anyone, which is why I skipped right over NPD to Schizoid Personality Disorder, premorbid to Schizophrenia, Paranoid Type, which presented later in his early 20's, probably the year before the massacre.

Mr. Kluger says that mass murderers like Cho and Harris and Kliebold (the Columbine murderers) suffered from "clinical narcissism"

a condition characterized by "disablingly low self-esteem, requiring the sufferer to seek almost constant recognition and reward."

He goes on to say that if a narcissist is denied recognition, especially if he has had a history of abuse and marginalization, he can become enraged, gradually moreso. A sense of powerlessness is replaced by a (my addition in parenthetic italics)

"heady experience that may produce an implacable serenity on the one hand (Cho), or the eerily jocular banter that surveillance tapes picked up between Harris and Klebold in Columbine on the other."

Kluger says that the gunman is calm because he knows he's right

". . .the world has brought the carnage upon itself."

I would say that yes, it looks like that, like Cho was confident in his decision to kill and felt justified, like he'd been harmed and was delivering vengeance. But in this case the gunman was calm, very probably, because he knew he was following the orders of the voices in his head that said, They've harmed you, cheated you, ignored you. Kill them. Soon.

The narcissist would be thinking for himself, the person with schizophrenia has help. The thoughts are the same, but the person with schizophrenia is hearing voices and is fearful, not righteously indignant like the narcissist.

This is why I'm not quick to join Time Magazine's journalist who concludes by saying that we can predict these things because murderers who suffer from clinical narcissism do tell people, even brag to others that they intend to perpetrate their crimes. Harris and Kebold said so on the Internet. I don't remember reading that that was the case with Cho at all. Who did he talk to? Did he tell someone? Am I missing something? It would have been difficult for anyone to read his mind. Again, it's very possible that we're missing information. We're only one week from the event. More will tumble out over the coming weeks, months and years.

So I'll stick to my original diagnosis of schizophrenia for now.

Nevertheless, this is a perfect example of why diagnosis per se is often a dead end and tells us little.

On the surface, Cho had most of the symptoms, if not all, of Narcissistic Personality Disorder. But it certainly wasn't a pervasive disorder as it didn't manifest until the episode, the massacre.
We don't even know if he slept. Perhaps he had a manic episode.

And if we add narcissism to Cho's Axis II disorders, does that mean we have to be very careful with every narcissistic adolescent we see? Normal adolescents can go through a very narcissistic phase but the grow out of it and everyone is grateful. Also, in NPD there is typically a LACK of self-destructiveness, impulsiveness, or concern with abandonment. You did this to me might be saying something about abandonment. Suicide IS self-destructive.

I think the key word to look at, forget the clinical diagnosis for a minute, is arousal. Screaming anxiety/anger, uncontrollable, painful arousal, likely caused by dysfunction of the limbic system and perhaps voices in his head or perhaps, as Kluger says, righteous indignation.

Thus when we send psycho-educational teams of mental health professionals and peer counselors to our schools to teach children about mental illness, as I've suggested on other posts, they will focus on communication and anger management. I am working on the program right now.

I base that trajectory, by the way, the Schizoid Personality Disorder premorbid to Schizophrenia upon what the American Psychiatric Association finds statistically significant in the data analysis of studies in the general and clinical populations. The DSM is a product of 13 Work Groups and a Task Force, consensus scholars without previously held views, who analyzed cross-cultural data.

By the way. This is not to say that people who do have personality disorders don't have some kind of genetic predisposition that presents as lacking empathy. We'll save empathy, however, for the next discussion.

Copyright 2007 TherapyDoc