Loughner: Schizophrenia or Terrorist

a Glock 19—a lightweight, $500 semi-automatic commonly carried by law enforcement officials—to kill six people and injure 13 more, including Rep. Gabrielle Giffords. In 2007, Cho Seung-Hui used the same gun, a along with a Walther P22, to kill 32 people at Virginia Tech before committing suicide. And Giffords herself boasted to the New York Times in 2010: "I have a Glock 9 millimeter, and I'm a pretty good shot."

Readers beat me up for jumping to say that James Lee Loughner probably suffers from Schizophrenia, Paranoid Type, hears voices in his head, follows their directives.

I’m urged to read Slate,

Seena Fazel is an Oxford University psychiatrist who has led the most extensive scientific studies to date of the links between violence and two of the most serious psychiatric diagnoses—schizophrenia and bipolar disorder, either of which can lead to delusions, hallucinations, or some other loss of contact with reality. Rather than looking at individual cases, or even single studies, Fazel's team analyzed all the scientific findings they could find. As a result, they can say with confidence that psychiatric diagnoses tell us next to nothing about someone's propensity or motive for violence.

I'm reminded that most people with schizophrenia do not buy guns and do not shoot people. They try to get help.

As advanced as we are, that should be true.  But many of our homeless suffer from severe mental illnesses like schizophrenia and refuse help.  Suspicion of others, negative attribution, is the nature of the disease.  And the onset isn't usually until adulthood, so the premorbid space, when a person is beginning to get sick, is often overlooked as an adjustment disorder or depression, even individuation.

The problem is that the suffering of schizophrenia is incomprehensible to “most.” We're told to avoid people who talk to themselves, and that's probably not bad advice.  It is a very complicated illness, attacks cognition and emotion, feels primarily like anxiety. Behavior seems irrational to others, strange.  Thinking is different, careful, afraid, comes from a dark place.  This is a vulnerable population.

So the complaint is leveled.  How dare a therapist link violence and mental illness?  Such a gross injustice to millions who suffer mental disease.  Never my intention to claim statistical significance in any way.   These are idiosyncratic cases, off the charts, outside the norm.

And the real menace is that Glock 19.

This is not to say  that the individuals who perpetrated mass murders within the past three years in this country were not mentally ill. Two mass murders at large schools, Virginia Tech and Northern Illinois University, young assailants suffering from schizophrenia.  Access to guns.  Jared Lee Loughner seems familiar. Social profile detached, expelled from community college pending mental status exam, a lesson, no doubt, from past school attacks. The sheriff says, 20/20 hindsight, We knew about Jared.

But still, jump to a diagnosis of mental illness when so many other things predict violent crime, and mental illness is usually not one of them?

Diagnosis is what therapists do, sorry. We make initial, provisional diagnoses. We consider context, but at the end of the day, we see the individual and it's our job to assess what hurts. Schizophrenia is an Axis I disorder, which implies the illness isn’t a function of personality development, or behavior. The disease itself hurts.

Social context affects that pain, can even predict the course of an Axis I disorder.   But in the case of schizophrenia, environment doesn't make it so. It is in the genes. Of the contextual variables associated with schizophrenia, the one thing we know is that it gets worse, symptoms “flare up,” when there is anger in the room.We urge families to tone it down.

We also know that the onset of the illness for young men tends to be young-adulthood, when developmental stressors collide with coping skills. Crunch time: What do I do with the rest of my life? I can’t live here forever!  And my skills, my learning even, seems limited. 

More hearsay about the Loughner case:

(a) neither of the two parents socialize with neighbors,
(b) his mother buys two cases of beer, 30 in each case, with the family groceries,
(c) she is the only one in the family holding down a steady job,
(d) neighborhood kids think of father as an angry man who irrationally yells at them
(e) only son Jared is considered odd, has access to the Internet, obsesses about political conspiracies, seems dangerous and disconnected to others, seems to be in his own world, laughs when no one else is laughing. 

We might think Jared is from an alcoholic family, was neglected/abused, perhaps an unfair assumption. We might wonder how anger affected him. And sure, we might diagnose him on the many spectrums of mental and behavioral illness, including autism/asperger’s, and attach various personality disorders, Axis II’s, the personality disorders, considering his odd behavior.   Or bullied, alienated, like millions of others, he found comfort on the Internet and inspiration for assassinations. Unhappy childhood, solace in socio-politics, a decision to end a quiet life of desperation with a bang. Save the world.

Not necessarily schizophrenia. But do we ignore a diagnosis of schizophrenia because it isn’t politically correct? Isn’t it possible that in some cases it can happen that people do hear voices or receive Internet messages that tell them to kill a dozen or so people in a supermarket parking lot?

Group statistics are there to find central tendencies, describe groups of people, averages over thousands. The men who pull triggers on innocent people are hardly average. They are so few and far between that they do not dent central tendencies. We’re grateful for that. Group statistics de-stigmatize. Most people who suffer from mental disorders are not violent. Would that we could say that about the non-clinical population.

These particular cases of mass murder are unique. We wouldn't be very interested in them if they were not. This is why I’m so interested when it happens. It does seem, in these cases of mass murder, that the offenders suffered from Schizophrenia, Paranoid Type.

We're not doing enough to detect and protect the mentally ill.

More salient to the issue is that everyone has access to guns, not only people who have no rational control, whose minds aren’t functioning in our reality, who should be on some medication, in groups, therapy, rehabilitation. Killing is glamorized on television fifty times a day, and in the movies, as are theoretical concepts, ideas about assassination, terrorism, taking justice into one’s own hands.

I used to think

terrorist = suicidal bomber packing nails and bolts on a bus

But why wouldn't terrorists use automatic weapons? We don't label terrorists with mental illness, we call them social activists with an agenda. What is gleaned from Loughner’s indecipherable rambling on the Internet is that he is anti-government, a terrorist, essentially. He has an agenda.  Something out there made sense to him.

Or others found him, perhaps a group sponsored his gun, ala  Lee Harvey Oswald. That's surely what they're saying.

But I'm putting my money, sad to say, on his illness.

therapydoc

Cho Copycat and Life is a Battlefield

On Saturdays, you know, I don't work. So I take it kind of slow, check out the weather, read the Wall Street Journal. If it's nice out I'll go outside and stare at the backyard, check for new buds, wild flowers, that sort of thing. We're pretty vegetation-starved by April in Chicago, and any sign of life makes us very happy.

If you haven't been in Chicago, by the way, in the springtime, when leaves and flowers are announcing themselves, literally bursting on the scene (with such drama), you're missing something. On a sunny day you can simply pass out it's so overwhelmingly stunning. It's like being in a musical. You half expect Julie Andrews to skip through the sidewalks, over the cracks, eyes dancing left and right at the rhododendrons singing, "The hills are alive, with the sound of music. . ."

Except we have no hills.

But yesterday, instead of reading my WSJ, I picked up my Chronicle of Higher Education. The Chronicle is THE journal to read if you're looking for a job in academe, or if you work in academe and want to read the trials and tribulations of other academics. Not only can you find out who is leaving which university and WHY, but you can get all kinds of ideas about teaching and what kids are learning these days.

So I read a couple of pieces in the Chronicle and thought, hmmm, which do I review for my blog, since a couple of them really grabbed me. One was a review of the intelligentsia on religion (why in the world would anyone believe in anything that can't be proven, dummy me and the rest of the Big 3 Abrahamic tradition-bound-cleaving public) and the other was about how important it is for people who work in academia to KEEP THEIR MOUTHS SHUT because everything they say in class can and will be posted on the Internet on some dissatisfied student's blog. Or worse yet, a video on YouTube.

Both would have been worthy things to blog about. However. . .

You know it was a beautiful day. And things happen. I locked up the house and headed off for shul (the synagogue), just feeling those allergies getting all excited and tingly. Across the street a neighbor walked her fabulous pedigreed dog. Let's call my neighbor Jill.

We waved.

Ordinarily I might have let it go at that and kept on my way, but it was a beautiful day, the kind of day you just don't hurry anywhere if you don't have to, so I crossed over to Jill to catch up with her news. We've never talked that much, but everyone on this block is really friendly and since nobody dares fight the cold to hang around and shmooze during the winter, spring is a kind of a social spring-time, too. So I was happy to stand on the street corner and talk with Jill.

Not that I got too close to the dog, I have to admit. Dogs like me, and I like dogs, I mean we have an understanding. But I don't like it when they simply have to show me how much they like me by jumping on me or licking me or sniffing at my skirt. I don't do the petting of the dog thing, and prefer a safe lunging distance. I hate it when they lunge.

"Oh, he won't jump on you," Jill says.

"I know, I trust him."

"He really won't."

"We're good, I'm okay," I say, reassuring her, yet stepping back another step.

She pulled the dog who was wagging his tail and drooling out of pure love and happiness, a little closer and asked me how long we've known each other. I thought about it. About 28 years. She was on the block when we moved here, I'm pretty sure. I've watched her kids grow and admired her dogs, too, for that long.

I asked about the boys, what were they doing, and she asked about mine. Somehow we got to talking about Cho. She asked had I read about what just happened in . . .she couldn't remember exactly where it was . . . Apparently some kid somewhere in the Chicago area wrote a story for class that really upset the teacher. . .full of spleen, murder, anger and hate. Just like one of Cho's plays.

"What happened?" I asked.

She couldn't remember the details, told me I could probably find the story online if I checked the Chicago papers. She reflected,

"Ya' know, my youngest was peer rejected, teased terribly as a little kid and he was pretty depressed. I'm really thankful that now, as an adult he's doing great. He survived his childhood."

I shared about my own kids' social angst, said that most of us do survive childhood, but it's not easy. It helps, of course, to have emotionally receptive families that encourage us to bounce off our feelings, express a little spleen.

We think most families are like that, emotion-sensitive, but many are not. In therapy I tell parents that they have to ask their children at the end of the school day:

Has anyone been mean to you, or picked on you today? How about your teacher? Was she nice to you? How was it out there in the big, world? Life is a battlefield, ya' know.

(Is life is a battlefield a Cheryl Crowe lyric, ? Talk about an interesting life/family!)

Jill, a teacher for many years, agreed. Life's a real challenge for every kid, much more so for some. The two of us could have talked for hours, but I really did want to get to shul, so I said goodbye to her and Poochie (name's changed, okay?!?) and headed off.

In shul, when my brain drifted to blogging, as it often does, I thought about this kid who copied Cho's writing style . I decided that that was more important to blog about that than whatever it was the Chronicle intelligentsia had me thinking about.

This morning I found the article Jill was talking about, and in the first draft of this post almost linked you over to the story. But after thinking long and hard about it I considered the idea that this kid's privacy has already been compromised, perhaps for good cause, who knows, but it wasn't right to add to his burden by announcing his name, yet again, on the Internet.

Let's call him John. One of the goals this month, apparently, for John's creative writing class was to learn to communicate ideas and emotions through writing. The students could write what they wanted but were warned that if they wrote something that posed a threat to self or others, the school could take action.

John was an excellent student. It sounds to me like he tried to meet the goals for the month but the caveat about posing a threat wasn't clear.

Either way, the teacher went, Gotcha'.

I don't think she did anything wrong. She reported the story to her supervisor and to the principal of the high school. They determined to report it to the police, and John was arrested for disorderly conduct. His father was interviewed and asked the first obvious question,

Is handing in a school assignment disorderly conduct?

What's a teacher to do? She couldn't risk another Virginia Tech!

I fantasize the following scene, bare with me if you're an educator, maybe it makes no sense.

The teacher reads the paper. She's upset, first tells a significant other who says, You have to turn this (him) in! The next day she tells her supervisor and the principal. They all agree that she should talk to the student alone, first. She arranges for that and addresses it like this, asks these questions in no particular order. . .

"Wow, John, that was quite a story. Do you mind if I ask you if it's based on your life or does it come from your imagination? Or where did it come from? Is it fiction? What do you hope to communicate by telling the story?"

The student answers. Then the teacher has the option of offering student resources at the school or outside mental health resources if appropriate. She might ask, "Are you upset about something? Do you have violent, real life thoughts? Would you like me to help you get a therapist, or maybe help get your family a therapist? It would all be kept confidential, maybe you'd feel better. We have to talk to your parents if we send you to see someone for help. "

The kid chose HER to tell his story. I feel she should have handled it first. Maybe she did. Maybe we don't have the whole story. The school, I'm pretty sure, can't offer a child any therapy or counseling without parental permission, at least I don't think so. But is there something wrong with that conversation before bringing in the parents and the police? I know that there are privacy rules, FERPA, the federal privacy act. I'm asking you educators out there for your opinions.

I know a teacher who once said,

"I'm not a rabbi. I'm not a priest. I'm not a minister or a psychologist.
Kids-- I don't wanna' hear about it."

Hey, I'm not judging.

In fact, I see many teachers who are in therapy who work in tough Chicago neighborhoods where it is common for students to walk away with anything teachers leaves on a desk when they step out of the room. On some days it feels to them like angry, sullen kids are in the majority and that haughty disrespectful, in-your-face behavior is the norm. Is a teacher supposed to help everyone of them? Any of them?

We have survivor research that indicates that people who survive family dysfunction and trauma in childhood can point to one person who saved them, who gave them the strength to get through adolescence, a person who said, You'll get out of here one day. You'll make it. Things will be better, you'll see.

Those people were often teachers.

And they didn't always have the kinds of chat I described above. More often than not, they simply showed that they cared, communicated that they understood the child's personal battlefield. To a degree, based upon the look on the child's face every day at school, based upon his writing, maybe they do understand. Empathy is medicine.

Empathy, however, is very difficult with belligerent and verbally violent children who may need to be admonished for their behavior in school, not patronized, whose families don't answer the phones because they're high or don't have a telephone that works, who need help but refuse to attend school to be there for the offer, who have already written off getting an education in favor of working the streets. Those kids are hard to reach.

The boy who wrote that story, the Cho copycat however, was not one of those difficult kids. The teacher might have tried talking to him, maybe she did. Reporting to the police did increase the odds he'd be evaluated by a psychiatrist, which he was, so maybe that was the administration's intent all along. Have him booked on something, then get him help. I've heard that before.

If a social worker like me were to work on a program to train educators to handle this problem, I'd need input from those of you with experience and ideas, who work in schools.

For sure leave a comment below and we can start talking (heck, anyone can do that anyway, I wrote about Lassie, didn't I?). Or you can email me at Therapydoc at gmail.com. I have to have made somebody angry with this post, right?

The lines are open.

Copyright 2007, TherapyDoc

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

Cho update

So it's looking as if my assessment in the last post wasn't all that far off.

Cho was a very silent guy during childhood, but went to school and managed to perform well in school. His detachment justifies a Schizoid Personality Disorder diagnosis, premorbid to Schizophrenia, Paranoid Type that presented at Virginia Tech in 2005, perhaps even earlier, in his early 20's. A very common onset for schizophrenia.

His final words, "But you decided to spill my blood. You forced me into a corner and gave me only one option. The decision was yours. Now you have blood on your hands that will never wash off."

To me that sounds as if he thinks he's the one who had been crucified 2 millenium ago (I'm admittedly no expert on this), a sign of schizophrenia, thinking you're the father of Christianity.

We still don't know if he was an abused child. It has been repeated in the news that his parents worked very hard and stressed achievement, which explains why he and his sister tried and did very well in school, despite whatever stressors they suffered. CNN quotes someone as saying that Cho's father said that he had to leave Korea to come to America "where no one knew him."

That sounds suspiciously like foul play somewhere, somehow. In any case, Cho's mental illness surely could have been flagged much younger.

My guess is that therapy docs will be seeing many very quiet children in the next few months, perhaps years, and that's for the best if you ask me.

I like quiet kids. They have a lot to say once you get them talking.

TherapyDoc

Cho Seung-Hui's Plays

Cho Seung-Hui, the student who killed 32 people at Virginia Tech, was a writer of "twisted plays." Ian McFarlane, his former classmate and a current employee at AOL has them.

Ian writes about Cho Seung-Hui at AOL

After hearing about the mass shootings, I sent one of my friends a Facebook message asking him if he knew anything about Seung Cho and if he could have been involved. He replied: "dude that's EXACTLY what I was thinking! No, I haven't heard anything, but seriously, that was the first thing I thought when I heard he was Asian."

While I "knew" Cho, I always wished there was something I could do for him, but I couldn't think of anything. As far as notifying authorities, there isn't (to my knowledge) any system set up that lets people say "Hey! This guy has some issues! Maybe you should look into this guy!" If there were, I definitely would have tried to get the kid some help. I think that could have had a good chance of averting yesterday's tragedy more than anything.

While I was hesitant at first to release these plays (because I didn't know if there are laws against it), I had to put myself in the shoes of the average person researching this situation. I'd want to know everything I could about the killer to figure out what could drive a person to do something like this and hopefully prevent it in the future. Also, I hope this might help people start caring about others more no matter how weird they might seem, because if this was some kind of cry for attention, then he should have gotten it a long time ago.

The plays are now posted on AOL and you can read them (unless you suffer from depression and I've been telling you to avoid disturbing news stories) by clicking on this link to that site

Now that's the power of the Internet. Amazing that we could read this if we wanted.

No, I haven't read the plays. I still have 2 more patients to see and even later, I don't know how much "twisted" I can take. But we were looking for the Why's in the last post, so here they are.