Follow-up to Mass Shooters and the Psychopathology Spectrum, by Ronald W. Pies, MD.
Core article concept: schizophrenia
In search of a silver lining to the recent focus on “mental illness” as a primary antecedent to mass shootings, we are hopeful that a much-needed dialogue about mental health might be stimulated. Characterizing mental illness in a way that is demystifying and readily understandable is challenging for mental health professionals, let alone the lay public. Nevertheless, we go in search of a place to begin our dialogue, and broad concepts seem better suited for a starting point than do highly granular views. In this vein, we would like to offer a dimensional approach that is now receiving vigorous attention—a single dimension view of mental health.1 Although this is not a new concept, there has been a burst of research around dimensionality and mental illness, leading some to assert it may be “superior” in terms of future scientific study.2
Dimensional approaches vary, but one approach aggregates psychiatric symptoms into three domains along a single dimension of psychopathology: 1) internalizing, 2) externalizing, and 3) psychotic experience. This tripartite dimensional approach is appealing—not only because of the robust research supporting it, but also because it can be used as an overarching structure by which much of mental functioning can be understood. The Table shows this dimensional approach, along with observations on how key psychological concepts cluster along what we should like to call a “spectrum of mental functioning.” This model is essentially old wine in a new bottle. Freud originally used this terminology in his paper, “The Loss of Reality in Neurosis and Psychosis.”3 Freud wrote that “neurosis does not disavow the reality, it only ignores it; psychosis disavows it and tries to replace it.”3 Thus, along our spectrum of mental functioning, Freud might point out that in each domain there is loss of reality—it is simply a matter a matter of how much. For the psychotic domain, the psychosis puts itself forth to replace reality entirely. In contrast, in the internalizing domain, only a piece of reality is shielded behind the relevant defense mechanism.
Such a dimensional approach may be used to measure an individual’s vulnerability to different types of mental disorder, comorbidity among disorders, persistence of disorders and severity of symptoms. Another way of viewing this approach is to see it as a big picture perspective, allowing for more readily understandable explanations of mental functioning along a spectrum. The model may also help make sense of the comorbidity frequently observed between certain disorders (i.e., anxiety and depression). Determining accurate diagnoses of mass shooters is difficult, largely due to the often-retrospective nature of the task and the lack of reliable psychological or psychiatric data on them. However, the use of a dimensional model to categorize their mental functioning may be an acceptable alternative method when key data sources are limited. This approach may also help clear up misconceptions about the rate of psychosis in mass shooters, as well as which population of individuals carry more risk. For example, a testable hypothesis might be that most mass shooters fall into the externalizing domain, given their personality structure, defense mechanism use, absence of clear psychotic symptoms and inability to internalize and process their intrapsychic conflict in a prosocial manner.
Taking Dr Pies’ vignette of 19-year-old Tyler, we can apply the dimensional model to understand his likely position on the mental functioning spectrum, as well as analyze some of his proximal warning behaviors.4 Tyler’s strong beliefs about being targeted for mistreatment and resentment over life being stacked against him suggest he is likely heavily weighted towards externalization. When under stress, it is possible he might regress along the spectrum towards developing mild to moderate thought distortions and/or worsening paranoia. Turning to his proximal warning behaviors, we find evidence of conducting research and planning (pathway), an increasing pathological preoccupation with a cause (fixation), and admiration for previous shooters (identification). These three warning behaviors have been found in most school shooters and lone actor terrorists, and in particular, pathway and identification have discriminated between attackers and nonattackers.5 We also see he has a personal grievance toward his high school, as well as a recent loss of a job. He has expressed ideological beliefs that may further his intent to act (anger towards minorities, resentment towards his school). Given his rants on social media, it is possible he has developed a dependence on a virtual community which supports and encourages his beliefs. These are further indicators of risk, particularly among lone actor terrorists.6
Las Vegas shooter analysis
As a thought experiment, let us apply the same approach to better understand the Las Vegas (LV) shooter who opened fire into a crowd from the 32nd floor of the Mandalay Bay Resort and Casino on October 1, 2017.7,8 This case was notable for many reasons, not the least of which was the shooter’s purported absence of motivation and apparent “private nature.”7 The Las Vegas Review Panel (LVRP) found no evidence suggesting the LV shooter was motivated by ideological or political beliefs. However, the panel concluded that his “intention to die by suicide was compounded by his desire to attain a certain degree of infamy via a mass casualty attack.”7 It was also found that he had stressors of declining physical health, a substantial need for control, and a history of manipulating others. Of note, he had demonstrated an ability to maintain some interpersonal relationships and did not completely isolate himself. He displayed at least some amount of concern and responsibility for his girlfriend and certain family members. There was no evidence he had ever experienced psychotic symptoms. He was intelligent, methodical and had achieved significant financial success in the real-estate business. He also applied his intellect to a favorite pastime—gambling—and claimed to have won significant sums by applying algorithms he had discovered to gambling on machines. The FBI noted that he “displayed minimal empathy throughout his life and primarily viewed others through a transactional lens of costs and benefits”—an interesting finding given his biological father’s history of psychopathy and criminal infamy.7
However, in his final months he appeared to be misusing alcohol, seemed despondent and was experiencing financial stress. He had also obtained prescriptions for diazepam from his physician. He was an avid firearms enthusiast and collector, and there was at least one report that he was concerned about escalating government restriction of firearm ownership. The FBI found that he “engaged in significant, methodical, Internet-based research regarding site selection, police tactics and response, and ballistics.”7 He also applied his methodical intellect to conducting in-person site surveillance and meticulously planned and ensured he would be in control of his own suicide. It did not escape the FBI’s attention that he was likely influenced by the memory of his father who had “achieved” significant criminal notoriety and was diagnosed as a psychopath by a psychiatrist in 1963. What is not said in the FBI report is the possibility of heritability of psychopathy in the shooter, given his father’s absence as an actual parent, yet biological contribution to his son’s personality.
Dr Knoll is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of Psychiatric Times (2010 to 2014).
Dr Meloy is Clinical Professor of Psychiatry at University California San Diego, La Jolla, CA.
The authors report no conflicts of interest concerning the subject matter of this article.
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