Tuesday, April 17, 2007

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.



TherapyDoc said...

I'm not sure why this didn't get published. I thought I pushed the right button. But thanks, ANONYMOUS.

Anonymous to me

Anonymous has left a new comment on your post "Virginia Tech Massacre":

Please be aware of the following breaking news story appearing on ABC News (http://abcnews.go.com/Health/VATech/story?id=3050483&page=1 )

Cho Likely Schizophrenic, Evidence Suggests A Closer Look at the Minds of Mass Shooters By MICHAEL WELNER, M.D.
April 17, 2007 — - Renowned forensic psychiatrist Michael Welner has examined some of the most notorious mass shooters of recent years. As details emerge about Seung-Hui Cho, the chairman of the Forensic Panel is following the case for ABC News and sharing his insights from his experience and current medical literature. Using the latest informaton, Welner believes the evidence strongly supports that Cho had paranoid schizophrenia.
Copyright © 2007 ABC News Internet Ventures

Not-faint-hearted said...

Thanks for writing this. I'm grateful that you have the ability to put words to what I sense only intuitively and without the education needed to express it. You have that education, the words and express it in a way I think most people should be able to understand.

This post will help me as I talk about this over the next days and weeks.

TherapyDoc said...

Great, it's what I wanted to do, FH.

Curiosity.Killer said...

I was really wondering about Cho as well. I read both his plays. It was so singular and angry.

Such a shame.

TherapyDoc said...

I read them, too, even though I didn't want to. If they were calls for help, they almost made it. His professor tried. He was at the point of no return, however, when he bought those guns.

No guns.

diane said...

I know a lot of people feel flashing this guy's face all over the media is only serving to glorify him, but I must say, I have been extra-interested in your blog the last couple days.
For years I have been interested in reading about the minds of killers (uh, which hopefully doesn't make me a nut??) and am currently reading two books about brain health.
I just hope the coverage enlightens more people, parents especially, about signs of dangerous mental illness. I know that no one could "force" this kid into therapy, but my god, at some point he should have been pulled out of school. He clearly did not have the mental or emotional health to function in such an environment. Obviously he had frightened other students and teachers. When do we say, "Look, enough!"?? Why do we consistently wait for something to happen and then shake our heads and say, "we should have known"??
His plays--yes, I read them too--lead me to wonder if he was abused as a child. But ultimately, I will never know, nor is it really my information to know.
I guess all we can hope for in such awful situations is that some learning comes from it. And my hope is that learning how to care for mentally ill youth for the security of themselves and others is one outcome.

TherapyDoc said...

So far I haven't really heard his history, nothing about his youth. I'm interested in finding out if he was one of the quiet kids who tried to please but didn't have the self to talk, or if he was simply totally detached from his mental illness.

Pigeon said...

I love your blog, it has been particularly helpful in the wake of this tragedy. Thank you!

Anonymous said...

I tend to agree with therapy doc. Cho clearly showed psychotic behavior. Two thoughts, his plays obssess with father figures one a teacher one a stepfather. Paternalistic hatred either of his real father or a man in power usually reflects a past traumatic experience with a "man in position of power". Cho phantasized about dominating and failing to dominate this "abuser" or paternal figure. Him and his "girlfriend" were openly persecuted by the figure. Also Cho coming from a deeply repressed paternalistic Koreon culture reflecting the "christ" mythological obssesions in his rantings and writings. In regards to Ismael to the religious and others, Ishmael and Hagar his mother are sent out by their father ,regected by abraham and break off to form the tribes associated with Islam. Cho is reflecting some sort of cast out, outsider, rejection by a father figure. Indeed it sounds like he fled or was sent aaway from Korea, his family background will be key in understanding who this boy was. Watch America's new obssession live as we all pick this guy apart and try and understand him. Makes me sad someone didnt take the kid by the hand and socialise him if it was even possible.

TherapyDoc said...

Dear Anon, Right on about Ishmail. We can pick Cho apart because he is our starkest reality right now, the poster child of mental illness.

My guess is that even as a child Cho was very suspicious and wouldn't have responded to kindness or others who undoubtedly did try to befriend him. That's not necessarily something that results from abuse, either, it can be endogenous, meaning biological, the brain's response to anxiety. For some that's paranoia.

Anonymous said...

I agree that his presentation (at least what we know from the media) suggests possible schizophrenia, a personality disorder, or perhaps an anxiety / mood disorder with paranoid ideation. I do wonder if as a child he fit a diagnosis of high functioning autism or Asperger's disorder. I haven't heard much in the media suggesting stereotyped, repetitive behaviors. It's also hard to know if any of his interests would qualify as restricted interests as seen in PDD. Language delays would rule out Asperger's. From my perspective, it would have taken a skilled clinician at an earlier age to tease out whether his poor language was due to a true language delay versus English being his second language coupled with issues such as severe anxiety, selective mutism, and paranoid ideation. I haven't read his writings, but suspect his written language was probably good given his level of education.

Who knows. This discussion is purely academic.... I can't help but ask the obvious question to anyone who works in the mental health field. Why the hell didn't anyone get this kid help??!! I know this is easy to say, but there were so many signs & time for intervention. It is a tragedy for him and all those he harmed.

TherapyDoc said...

Great comment, ANON. I'm thinking he was a quiet, sullen kid who understood enough to get by but never responded. The squeaky wheel gets the oil thing.

Something tells me we'll all be a little more mindful, and yet if he really didn't have the words, how could he have told a caring person?

It's a very tough call, and you're right, the assumption that there's a language barrier probably threw everyone off.

Anonymous said...

Therapy Doc,

I believe you to be absolutely correct in your diagnoses, particularly the schizoid personality disorder. For whatever reason I have made idle attempts to convince others as they rave about Cho having autism/psychopathy/being "evil"/ that these are incorrect assumptions, but the concept of personality disorder is a difficult one for the general public. Which is probably why we haven't been hearing much about that in the media, as it would only add to the confusion. I feel that it is important to try to correct these assumptions so that people do not develop unfounded fears of the autistic. They should fear the psychopath/ASPD'er, but need to understand what to look for, ie charming liars who take advantage, rather than loners.

In addition to the criteria from the DSM you listed, per the DSM, schizoid personality disorder in children is often misdiagnosed as autism.
Per the DSM once they are temporarily comfortable with someone they may reveal sadness over their isolation. Remember how Cho cried when his professor asked him if he was lonely?

And I agree with you that he did not display the features of antisocial personality disorder, particularly given that he committed suicide. ASPD'ers usually really enjoy living (and living off others) and live for the "con", therefore are constantly seeking association with others. He was not glib or charming like an ASPD'er, and was probably completely disinterested in conning anyone. The only thing he had in common with ASPD would be a lack of empathy, which is also one of the criteria for schizoid.

I wonder if there is any data on the crime/murder rates for schizoids, I rather doubt the data exists, given that they are rarely diagnosed/do not present in clinical situations. It would have to be just armchair speculation such as we are doing. Perhaps a rate of development of psychosis would be available.

I believe that had Cho been living in a different environment in which those who are different are tolerated and treated with kindness rather than teased, he would have lived a solitary life without things coming to this horrible conclusion. I wish the media would focus some more attention on the humane treatment of those who are "different". That would be the only way to prevent those 30+ deaths from being completely meaningless.

You are spot on in your assessments and I have added your blog to my "favorites".

Foster MD

TherapyDoc said...

You wrote,

I believe that had Cho been living in a different environment in which those who are different are tolerated and treated with kindness rather than teased, he would have lived a solitary life without things coming to this horrible conclusion.

I've thought about how another culture, perhaps a tribal culture, might handle people like Cho and the picture into my head is


I think that in a small village people are more likely to trust and care for one another. Maybe I'm way off but perhaps industrialization has something to do with our misunderstanding and maltreatment of people who are different.

People think, Who has the time?

Anonymous said...

Some professionals believe that schizoid personality disorder is actually a form of high-functioning autism. If Cho had autism with those features, the isolation, stress and anxiety of living in a world he couldn't understand would predispose him to all of the above.

TherapyDoc said...

I can see that. It makes sense. Someone sent me a link to research on this and I'm going to get to it as soon as I can.

Anonymous said...

You might find this link helpful. It was written by an autistic man about what his life was like pre-diagnosis.

Also research done by Lorna Wing, written about by Uta Frith describes the variations of higher functioning autism in three general categories of aloof, passive and active but odd. The aloof crowd is the least visible and the least written about.


TherapyDoc said...

Thanks, Anon.