"Mentally ill" people and mass shootings

[chajjohnson]

Anyone else a little frustrated with how mental illness is portrayed after mass shootings like this? In the wake of the shooting in Las Vegas it became known that the shooter was an older, white male from Nevada with no obvious radical political or religious associations. In searching for a reason how or why this person could commit such an awful tragedy it seems the general consensus the public and media have come to is to put the blame on "mental illness". I'm not saying this guy did or did not have a mental illness, and some would probably argue that committing a mass murder is basically diagnostic of some sort of mental illness (ASPD?). However, I feel like the tone people are taking against "mental illness" is absolutely destructive. There is already a significant stigma against mental illness, now people will assume everyone with any mental illness is liable to commit mass murder. The Jimmy Kimmel video going around the web () takes what I felt was a very harsh tone against everyone with mental illness. The fraction of people with any mental illness who have a tendency to be violent is minuscule. It actually reminds me a lot of the rhetoric against muslims after terrorist attacks. This talk of mental illness comes up after every mass shooting committed by a white person and I just don't know how to be more productive or accurate in where to place blame and suggest solutions.

Also, if laws were enacted as suggested in the Jimmy Kimmel video to ban gun sales to people with mental illness, would the responsibility be on psychiatrists to decide who can and can't get guns? Jimmy says to ban gun sales to everyone with mental illness but that is ridiculous. Someone with GAD or MDD should probably be able to buy a gun. Would certain diagnoses automatically prohibit a person from buying guns, or would a history of violence or certain risk factors be needed? Do you think a law like this could ever work out in a productive, fair manner? I haven't heard anything about the most recent shooter being diagnosed with any mental illness so I really don't understand where this is coming from.

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[WisNeuro]

Mental illness is just trotted out anytime this happens in a non-foreign terrorist situation to make people feel better. People need a reason, any reason, so they can sit back and continue to do nothing until it happens again. But, yes, I agree that it is negative for MH stigma purposes. I am all about expanding access and affordability of MH care, but this largely misguided rhetoric is not the way.

 

[wolfvgang22]

Voters in the U.S. have made it clear they are not interested in having their government do anything resembling more gun control, substantially improving mental health care, work on changing our violent culture, or improving the social safety net, especially if it involves increasing taxes. These choices have consequences, as we see multiple times a year. I'm tired of getting worked up about it. It is clear that the know nothings, do nothings have won for now.

 

[leslieknope2]

Anyone else a little frustrated with how mental illness is portrayed after mass shootings like this? In the wake of the shooting in Las Vegas it became known that the shooter was an older, white male from Nevada with no obvious radical political or religious associations. In searching for a reason how or why this person could commit such an awful tragedy it seems the general consensus the public and media have come to is to put the blame on "mental illness". I'm not saying this guy did or did not have a mental illness, and some would probably argue that committing a mass murder is basically diagnostic of some sort of mental illness (ASPD?). However, I feel like the tone people are taking against "mental illness" is absolutely destructive. There is already a significant stigma against mental illness, now people will assume everyone with any mental illness is liable to commit mass murder. The Jimmy Kimmel video going around the web () takes what I felt was a very harsh tone against everyone with mental illness. The fraction of people with any mental illness who have a tendency to be violent is minuscule. It actually reminds me a lot of the rhetoric against muslims after terrorist attacks. This talk of mental illness comes up after every mass shooting committed by a white person and I just don't know how to be more productive or accurate in where to place blame and suggest solutions.

Also, if laws were enacted as suggested in the Jimmy Kimmel video to ban gun sales to people with mental illness, would the responsibility be on psychiatrists to decide who can and can't get guns? Jimmy says to ban gun sales to everyone with mental illness but that is ridiculous. Someone with GAD or MDD should probably be able to buy a gun. Would certain diagnoses automatically prohibit a person from buying guns, or would a history of violence or certain risk factors be needed? Do you think a law like this could ever work out in a productive, fair manner? I haven't heard anything about the most recent shooter being diagnosed with any mental illness so I really don't understand where this is coming from.

Use your power as a psychiatrist and diagnose Jimmy Kimmel with a mental illness.

 

[Shikima]

Have to ask, how much of the individualization will be given up if a population is socially constructed and controlled not to exhibit such mannerisms/behaviors?

 

[wolfvgang22]

Have to ask, how much of the individualization will be given up if a population is socially constructed and controlled not to exhibit such mannerisms/behaviors?

I personally think there is a better balance point in improving our culture way, way before having to worry about this.
But, the rest of the U.S. doesn't agree with me though and is ok with they way things are so far. Wring hands, buy more guns, ignore problems, repeat in a month.

 

[Shikima]

I personally think there is a better balance point in improving our culture way, way before having to worry about this.
But, the rest of the U.S. doesn't agree with me though and is ok with they way things are so far. Wring hands, buy more guns, ignore problems, repeat in a month.

That's the problem, culturally and spiritually we're devoid of substance. Highly spoiled and materialistic. A 60s style communism crusade won't create enough change for personal responsibility, quite the opposite is at play now and further enhanced by social media.

For many eons this kind of behavior and thinking has been prevalent in many societies leading to many turning a blind eye to it - "It's not my problem." "Someone else needs to fix this." "You need a psychiatrist" (which is often used a pejorative).

 

[OldPsychDoc]

‘No Way To Prevent This,’ Says Only Nation Where This Regularly Happens

 

[thoffen]

‘No Way To Prevent This,’ Says Only Nation Where This Regularly Happens

It took me far too long to realize that was an Onion article.

 

[WisNeuro]

It took me far too long to realize that was an Onion article.

I believe that this is the 5th time they've posted that article. They just change the location each time.

 

[Mad Jack]

To call it mental illness without any prior diagnosis or noted signs and symptoms is absurd. For all we know his decisions were perfectly within whatever belief structure he had constructed for himself, like any terrorist (whom we do not classify as mentally ill). Maybe he just wanted to be famous, and he figured this was the best way to go about it before he died of old age. That's twisted, but not necessarily a thought process that required mental illness. For all we know he was an anti-gun crusader that figured he'd make a grand statement about firearms by unleashing rounds in the very sort of people that support liberal gun regulations, he could have had any number of motives that don't breach the point of mental illness.

 

[Fan_of_Meehl]

To call it mental illness without any prior diagnosis or noted signs and symptoms is absurd. For all we know his decisions were perfectly within whatever belief structure he had constructed for himself, like any terrorist (whom we do not classify as mentally ill). Maybe he just wanted to be famous, and he figured this was the best way to go about it before he died of old age. That's twisted, but not necessarily a thought process that required mental illness. For all we know he was an anti-gun crusader that figured he'd make a grand statement about firearms by unleashing rounds in the very sort of people that support liberal gun regulations, he could have had any number of motives that don't breach the point of mental illness.

This guy has some interesting ideas on the topic:

 

[Mad Jack]

This guy has some interesting ideas on the topic:

I was actually just thinking about that lecture yesterday. Peterson is the man.

 

[FlowRate]

I think most of these shootings are "mental illness" insofar as ASPD and related PD are "mental illness." But it's not like these folks are showing up to our ED responding to blanket nursing questionnaires that yes, they've had some homicidal ideation today, even though that's not the original reason they came to the ED today. No amount of increased funding for group homes, CMHC's, housing for the homeless, etc. are going to "save us" from rich white dudes or the children of rich white dudes. Of course, the odds of being involved in something like this are low overall.

I say white dudes because, of course, the "mass shootings" (and majority of gun murders IIRC) that go unreported (on a regional/national level) are often labeled "gang violence" and don't tend to feature mostly white folks.

 

[PsyDr]

It is a logical fallacy that one must suffer from a mental illness to commit a mass murder. And a sloppy one at that.

Since no IRB on the planet would approve an experimental design we do not know if mental illness causes mass shootings. So we cannot say "Mental illness causes mass shootings." As most mass murders die in their sprees, we do not know what their psychiatric disorders were. So we cannot even say there is a higher prevalence of mental illness in mass shooters. This prevents us from saying A causes B.

The empirical literature indicates that the mentally ill are more likely to be victims of crimes than commit crimes. The only disorders associated with an increased odds ratio of violence include alcohol use, marijuana use disorder, antisocial personality disorder, and delusional disorder. Which leads to minimal evidence that because B, A. .

 

[erg923]

I think most of these shootings are "mental illness" insofar as ASPD and related PD are "mental illness."

Why?

ASPD is not, and has nothing to do with a single act of commission, even if said act is grotesque, evil and makes no sense to anyone but him.

 

[Evidence Based]

The empirical literature indicates that the mentally ill are more likely to be victims of crimes than commit crimes. The only disorders associated with an increased odds ratio of violence include alcohol use, marijuana use disorder, antisocial personality disorder, and delusional disorder. Which leads to minimal evidence that because B, A. .

I've heard this statement thrown around a lot. Anyone have the paper it's from handy? Would love to have it on-hand for the future.

 

[WisNeuro]

I've heard this statement thrown around a lot. Anyone have the paper it's from handy? Would love to have it on-hand for the future.

From a lot of papers, many cite the MacArthur Risk Assessment Study as an early work in the area.

Violence and mental illness: an overview
Mental illness and violence - Harvard Health
Violence and Mental Illness
Deranged and Dangerous: When Do the Emotionally Disturbed Resort to Violence?

Those will be a good starting point, if you want further reading you can citation track from these.

 

[MedMan80]

Just want to add that this guy apparently set up cameras outside of his room so he could see police coming in..that level of organization rules out him being floridly psychotic or manic IMHO

 

[WisNeuro]

Just want to add that this guy apparently set up cameras outside of his room so he could see police coming in..that level of organization rules out him being floridly psychotic or manic IMHO

I generally agree, but wouldn't rule out hypomania. I've had pts be fairly productive and organized in hypomanic periods. Of course, these are the vast exception, and not the rule. But yeah, it seems that this guy had some pretty extensive planning going on, to the level that would exclude a lot of SPMI.

 

[Evidence Based]

From a lot of papers, many cite the MacArthur Risk Assessment Study as an early work in the area.

Violence and mental illness: an overview
Mental illness and violence - Harvard Health
Violence and Mental Illness
Deranged and Dangerous: When Do the Emotionally Disturbed Resort to Violence?

Those will be a good starting point, if you want further reading you can citation track from these.

Thanks so much!

 

[birchswing]

Well, he was on 10 mg Valium per day, reduced from his previous prescription of 20 mg per day. Steep drop. Could withdrawal have been a factor (obviously among many)?

Either way, he was at least nominally given a psychiatric diagnosis in order to have a prescription for a Schedule IV psychiatric drug.

I expected benzos (they are the most popular psychiatric drug by prescription). The dose is more modest than I would have expected.

 

[WisNeuro]

Given a diagnosis and having a disorder of a given diagnosis are two very different things. I have many patients with a psychiatric disorder listed in their problem list who definitely do not meet criteria for said disorder and are prescribed psychotropics.

 

[erg923]

Either way, he was at least nominally given a psychiatric diagnosis in order to have a prescription for a Schedule IV psychiatric drug.

1. No it doesn't.

2. Withdrawal syndromes make people sick and agitated. Last time I check, stockpiling weapons and meticulous planning of mass murder are not induced by bezo withdrawal.

2. The psychiatricizing of bad behavior is a huge problem

 

[birchswing]

1. No it doesn't.

2. Withdrawal syndromes make people sick and agitated. Last time I check, stockpiling weapons and meticulous planning of mass murder are not induced by bezo withdrawal.

2. The psychiatricizing of bad behavior is a huge problem

1. How does a doctor prescribe a medicine without indicating a disease? I thought they had to at least in name.
2. I agree; that's why I said one of many possible factors. Assuming there's not a slam-dunk explanation, there can be many little influencers. Obviously he was not in the throes of withdrawal or status epilepticus to orchestrate what he did. But if it's one of those things that ends up having no real good answer and instead has a multi-facted attempt at an explanation, that could be one very, very small part in an idiographic explanation.

Given a diagnosis and having a disorder of a given diagnosis are two very different things. I have many patients with a psychiatric disorder listed in their problem list who definitely do not meet criteria for said disorder and are prescribed psychotropics.

Yes, that's why I said nominally. The person prescribing it has some justification in their own mind about why it's appropriate to dole out scheduled substances on a long-term basis. And they write something down--some mental illness. But even if that's just in name only to them, what type of "distress," for lack of better word, would they be giving it for? It's certainly not for constipation. It's something behavioral. It doesn't mean they're right in doing it, but that's their thinking at least.

 

[WisNeuro]

Yes, that's why I said nominally. The person prescribing it has some justification in their own mind about why it's appropriate to dole out scheduled substances on a long-term basis. And they write something down--some mental illness. But even if that's just in name only to them, what type of "distress," for lack of better word, would they be giving it for? It's certainly not for constipation. It's something behavioral. It doesn't mean they're right in doing it, but that's their thinking at least.

Yes, but in the context of the current conversation, the implication of your current statement was that the gunman had a mental illness because he was prescribed a psychotropic. The fact in the current system, especially for benzos, is that you don't have to have a psychiatric disorder to get a benzo prescription. Many people get them when they complain about run of the mill life stress. My comments were more geared towards the notion that the fact that he was given valium is very low on specificity in the current discussion.

 

[erg923]

1. How does a doctor prescribe a medicine without indicating a disease? I thought they had to at least in name.

What do you mean "how"? They write a Rx. PCP's will write scripts for normal grief/bereavement, stress due to unemployment, moves, etc. Its not right. It just is.

 

[hamstergang]

Yes, that's why I said nominally. The person prescribing it has some justification in their own mind about why it's appropriate to dole out scheduled substances on a long-term basis. And they write something down--some mental illness. But even if that's just in name only to them, what type of "distress," for lack of better word, would they be giving it for? It's certainly not for constipation. It's something behavioral. It doesn't mean they're right in doing it, but that's their thinking at least.

Valium is also given for muscle spasms, pain, and certain sleep issues. So it's not definitely a psychiatric diagnosis.

 

[FlowRate]

Why?

ASPD is not, and has nothing to do with a single act of commission, even if said act is grotesque, evil and makes no sense to anyone but him.

I was trying to say that these things seem to be more "Axis 2" than "Axis 1." But I'd imagine that most laypeople think of "Axis 1" disorders when they use the phrase "mental illness." I did not mean to imply that shooting a bunch of people earns you a diagnosis of ASPD.

Moreover, the point is that even if they are "Axis 1" motivated acts, they're not "Axis 1" in a way that has anything to do with the usual proposals for how to fix the problem (raise awareness, psychopathology databases so people with MDD can't buy guns, increased funding for mental health.)

To further address the OP, where do we draw the line for "mentally ill" if we're restricting gun ownership for the "mentally ill?" That's what Jimmy and so many other people are calling for. Now we're just giving Joe Bob in Macon, GA another reason to resist going to see a psychiatrist for his run-of-the-mill Major Depression.

 

[thoffen]

Most lay people who don't have close exposure to mental illness have no clue what mental illness is, and even when given accurate information there isn't likely much realistic comprehension. They are more likely still to have this man's picture in mind when thinking about mental illness because it matches their experience, even though anything resembling his actions are exceptionally rare.

 

[smalltownpsych]

It is not a sign of mental illness for humans to kill each other. Might even be able to say that it is the norm. Non-violence is the exception in human history not the rule. I think it was Freud that said civilization is a thin veneer over primal instincts. Slavery, French revolution, WWI, WWII were not so long ago. Maybe these few crackpots are the inevitable price we pay as our culture goes through it's growing pains and struggles to become primates who are more like the gorillas in the mist and less like the chimps at Gombe.

 

[clausewitz2]

To further address the OP, where do we draw the line for "mentally ill" if we're restricting gun ownership for the "mentally ill?" That's what Jimmy and so many other people are calling for. Now we're just giving Joe Bob in Macon, GA another reason to resist going to see a psychiatrist for his run-of-the-mill Major Depression.

It is somewhat upsetting how frequently I have this conversation in our psych ED with country boys:

Me: I would like you to sign into the hospital because you have started drinking thirty beers a day, are giving away your possessions to your friends, sleep a couple hours a night, keep texting your family about how things will be better when you are gone, and are telling me when I ask about safety planning that you have access to any tool you would need to kill yourself.

Country boy: Naw, doc, I'm good.

Me: if you are involuntarily hospitalized in the state of Pennsylvania you will basically never be allowed to own guns again

Country boy: where's the d*mn form, do you have a pen.

Seriously though I am enormously pro-gun control but in a society where gun ownership is common and a cultural touchstone for many people I want to punch Jimmy Kimmel for suggesting that a psychiatric diagnosis should mean you don't have rights.

 

[PikminOC]

Just want to add that this guy apparently set up cameras outside of his room so he could see police coming in..that level of organization rules out him being floridly psychotic or manic IMHO

James holmes?
The guy in Arizona who shot the congresswoman? Jared laughtner i think

 

[nancysinatra]

Well, he was on 10 mg Valium per day, reduced from his previous prescription of 20 mg per day. Steep drop. Could withdrawal have been a factor (obviously among many)?

Either way, he was at least nominally given a psychiatric diagnosis in order to have a prescription for a Schedule IV psychiatric drug.

I expected benzos (they are the most popular psychiatric drug by prescription). The dose is more modest than I would have expected.

Valium is an anti-seizure medication.

Benzos, especially versed, are used in anesthesia. It is totally incorrect to claim that just because a person has been administered a benzodiazepine, that they were "nominally" given a "psychiatric diagnosis."

 

[slappy]

It is somewhat upsetting how frequently I have this conversation in our psych ED with country boys:

Me: I would like you to sign into the hospital because you have started drinking thirty beers a day, are giving away your possessions to your friends, sleep a couple hours a night, keep texting your family about how things will be better when you are gone, and are telling me when I ask about safety planning that you have access to any tool you would need to kill yourself.

Country boy: Naw, doc, I'm good.

Me: if you are involuntarily hospitalized in the state of Pennsylvania you will basically never be allowed to own guns again

Country boy: where's the d*mn form, do you have a pen.

Seriously though I am enormously pro-gun control but in a society where gun ownership is common and a cultural touchstone for many people I want to punch Jimmy Kimmel for suggesting that a psychiatric diagnosis should mean you don't have rights.

Is that true?

 

[slappy]

Because if it is, has anyone analyzed gun violence in PA and compared it to other states to prove/disprove many of these (mis)conceptions? Seems like a missed opportunity.

 

[clausewitz2]

Is that true?

So if you are involuntarily committed in PA, you lose the right to own firearms. There is in principle an appeal process but it takes many years, has no guarantee of success, and hardly anyone does this.

 

[slappy]

So if you are involuntarily committed in PA, you lose the right to own firearms. There is in principle an appeal process but it takes many years, has no guarantee of success, and hardly anyone does this.

Ah, committed, not hospitalized.

 

[clausewitz2]

Ah, committed, not hospitalized.

There's not a distinction in PA. Either you sign in voluntarily or you are hospitalized under the procedure outlined in section 302 of the PA Code, which is the same section anyone uses to petition for involuntary transportation to a designated facility for psychiatric evaluation.

 

[SeniorWrangler]

This is not an argument that psychiatrists are ever going to win, because to the average guy, shooting up a bunch of people you don't know for no apparent reason sounds like a crazy thing to do.

 

[smalltownpsych]

This is not an argument that psychiatrists are ever going to win, because to the average guy, shooting up a bunch of people you don't know for no apparent reason sounds like a crazy thing to do.

True that. My wife was asking me about the shooter yesterday along the lines of "what makes someone do that?" When I told her I had no idea, she said I should know something since I am a psychologist.
My response, which I thought was pretty good at the time, was that understanding the nature of evil is beyond my scope of practice.

 

[WisNeuro]

Meh, I think good and evil are just terms we use to make our selves feel better about things we don't understand. Plenty of "good" people do "evil" things. and vice versa. It's all just human behavior, we just might not have all of the variables in our regression equation to understand it sometimes.

 

[PsyDr]

Is that true?

Ahhhh, one of my favorites.

So if you are involuntarily committed in PA, you lose the right to own firearms. There is in principle an appeal process but it takes many years, has no guarantee of success, and hardly anyone does this.

This is a FEDERAL LAW. Not a state law. It was created in 1968 after a certain someone bought a rifle through the mail and shot a certain popular politician. This made it illegal for anyone who had been involuntarily committed to a psychiatric hospital and/or anyone addicted to a substance to own a firearm. In 1993, the brady bill created a reporting system called NICS. Which received other funding in 2007. HIPPA doesn't prevent this disclosure, although the GAO and HHS have indicated a provider can only report the name of the individual, and not clinical data including dx.

How many people are taught this? Pretty much none. I would imagine that there is going to be a legal storm when some attorney tries to place partial blames on a clinician for NOT reporting an assailant to NICS. Think about how many patients with substance abuse are sitting in your medical records. Because that started to happen after the viriginia tech shooting. Only thing that saved everyone was a lack of clarity in the law.

 

[leslieknope2]

Ahhhh, one of my favorites.




This is a FEDERAL LAW. Not a state law. It was created in 1968 after a certain someone bought a rifle through the mail and shot a certain popular politician. This made it illegal for anyone who had been involuntarily committed to a psychiatric hospital and/or anyone addicted to a substance to own a firearm. In 1993, the brady bill created a reporting system called NICS. Which received other funding in 2007. HIPPA doesn't prevent this disclosure, although the GAO and HHS have indicated a provider can only report the name of the individual, and not clinical data including dx.

How many people are taught this? Pretty much none. I would imagine that there is going to be a legal storm when some attorney tries to place partial blames on a clinician for NOT reporting an assailant to NICS. Think about how many patients with substance abuse are sitting in your medical records. Because that started to happen after the viriginia tech shooting. Only thing that saved everyone was a lack of clarity in the law.

I think it varies by state, sir. http://www.ncsl.org/research/civil-...session-of-a-firearm-by-the-mentally-ill.aspx

 

[PsyDr]

State laws absolutely vary. Nics, the Bradley bill, etc are federal laws. Because... you know they didn't really like it when someone killed Kennedy. And they said it was unamerican to not support this the bill.

As you are aware, our constitution says that federal law supersedes state law. Since gun sales are federally regulated, I doubt anyone prohibited on nics is gonna be successful in a state's argument.

There are some pretty interesting things happening with states refusing to report to nics. Ssdi and the va have argued that they shouldn't have to report people who have payees.

My bet is on someone looking for a payout is gonna sue a provider under the third party duty case law when they can.

 

[leslieknope2]

State laws absolutely vary. Nics, the Bradley bill, etc are federal laws. Because... you know they didn't really like it when someone killed Kennedy. And they said it was unamerican to not support this the bill.

As you are aware, our constitution says that federal law supersedes state law. Since gun sales are federally regulated, I doubt anyone prohibited on nics is gonna be successful in a state's argument.

There are some pretty interesting things happening with states refusing to report to nics. Ssdi and the va have argued that they shouldn't have to report people who have payees.

My bet is on someone looking for a payout is gonna sue a provider under the third party duty case law when they can.

But.. Some With Histories of Mental Illness Petition to Get Their Gun Rights Back

 

[PsyDr]

But.. Some With Histories of Mental Illness Petition to Get Their Gun Rights Back

Absolutely their right to seek legal restoration of their constitutional rights. Not my job to decide if they should have them or not, and I'm thankful that it's not. I do know that the law says I'm supposed to report, and that there have been inroads to making me liable if I don't.

 

[clausewitz2]

Absolutely their right to seek legal restoration of their constitutional rights. Not my job to decide if they should have them or not, and I'm thankful that it's not. I do know that the law says I'm supposed to report, and that there have been inroads to making me liable if I don't.

Our involuntary hospitalization/commitment process does not actually give us the option not to report. When we sign the petition it is automatically sent to a state police database in PA. They do definitely visit the homes of people who pop up in this data base sniffing around for guns. So federal law or not, it is enforced fairly automatically and broadly in PA in a way it might not be in other places. If, say, NJ was more haphazard about this the kind of work @slappy suggested might be very interesting.

 

[WingedOx]

This is not an argument that psychiatrists are ever going to win, because to the average guy, shooting up a bunch of people you don't know for no apparent reason sounds like a crazy thing to do.

Though calling out lazy journalism like this would help a bit.

Report: Suspected Las Vegas gunman was prescribed medication that can cause aggression

 

[WisNeuro]

Though calling out lazy journalism like this would help a bit.

Report: Suspected Las Vegas gunman was prescribed medication that can cause aggression

Next they'll report that he had a concussion once, like 30 years ago, and he probably did it because he has CTE.