VT killer let go from mental hospital

[tennreb]

Be careful, residents....

VT Killer Ruled Mentally Ill by Court; Let Go After Hospital Visit
Harassed Two Female Students; Concerns He Was Suicidal
By NED POTTER and DAVID SCHOETZ

April 18, 2007 — - A Virginia court found that Virginia Tech killer Seung-Hui Cho was "mentally ill" and potentially dangerous. Then the state let him go.

In 2005, after a district court in Montgomery County, Va., ruled that Cho was either a danger to himself or to others -- the necessary criteria for a detention order -- he was evaluated by a state doctor and ordered to undergo outpatient care.

According to the "Temporary Detention Order" obtained by ABC News, the doctor found Cho's "mood is depressed."

"He denies suicidal ideation. He does not acknowledge symptoms of a thought disorder," the doctor wrote. "His insight and judgment are normal."

The evaluation came from a psychiatric hospital near Virginia Tech, where Cho was taken by police in December 2005, after two female schoolmates said they received threatening messages from him, and police and school officials became concerned that he might be suicidal.

That information came to light two days after Cho, a Virginia Tech senior, killed 32 people and then himself in a shooting rampage on the university's campus.

Virginia State Police this afternoon also announced that NBC News received a package they believe was sent to the network by Cho.

NBC immediately alerted authorities, police say, and handed over copies of the contents, which included "multiple photographs, video and writings," according to Virginia State Police Superintendent Col. Steven Flaherty.

Authorities hope the package may help authorities better understand the killer's motivations as evidence of his previous mental issues mounts.

Police obtained the 2005 detention order from a local magistrate after it was determined by a state-certified employee that Cho's apparent mental state met the threshold for the temporary detention order.

Under Virginia law, "A magistrate has the authority to issue a detention order upon a finding that a person is mentally ill and in need of hospitalization or treatment.

"The magistrate also must find that the person is an imminent danger to himself or others," says the guideline from Virginia's state court system.

Wendell Flinchum, the chief of the Virginia Tech police department, said that it's common for university police to work with state-affiliated mental health facilities instead of on-campus counseling because it is easier to obtain a detention order.

"We normally go through access [appealing to the state's legal system for help] because they have the power to commit people if they need to be committed," Flinchum said at a press conference Wednesday morning.

Cho was taken to Carilion St. Albans Behavioral Health Center in Radford, Va., a private facility that can take 162 inpatients, according to court documents.

It's unclear whether Cho went to the hospital with police on his own or was taken there under protective custody, a possibility under the temporary detention order obtained by police.

Authorities did not say how much time Cho had spent at the hospital.

One of the young women complained in November 2005 that Cho, then 21, was stalking her, but she declined to press legal charges against him. Police interviewed Cho for the first time and referred the case to the school's internal disciplinary board.

It's unclear whether any action was ever taken by the school, although Edward Spencer, a school vice president, said that it's not uncommon for a complaint to never reach a full hearing.

A second girl, less than two weeks later, told authorities she received disturbing instant messages from Cho, and asked police to make sure there was "no further contact" from him.

Police spoke to Cho the next day. They say that shortly after, they received a call from an acquaintance of his, expressing concerns that he might be suicidal.

For a third time, police met with him. "Out of concern for Cho, officers asked him to speak to a counselor," Flinchum said. "He went voluntarily to the police department."

Police say Cho talked with a therapist from a local mental health agency not affiliated with Virginia Tech. That agency had authority to seek the detention order from a local magistrate.

The student complaints that brought Cho to the attention of authorities came during the same time that creative writing professor Lucinda Roy went to administrators to voice her concern about violent themes in Cho's writing.

Roy told ABC News that Cho seemed "extraordinarily lonely -- the loneliest person I have ever met in my life."

But authorities said they had no contact with Cho between then and Monday's mass killings.

While the school, citing privacy laws, did not conclusively say that school counselors had ever worked with Cho, they did say that a system for working with outside mental health agencies and local authorities is in place.

"Clearly, mental health professionals have a legal and moral responsibility," when a student presents a possible risk, said Christopher Flynn, head of the university's counseling center. "We have a duty to warn."

But Flynn also said that signs of trouble in Cho's behavior were not a clear indicator that action would follow. "It is very difficult to predict when what someone perceives as stalking, is stalking."

A Loner, Mysterious Even to His Roommates

Seung Cho was quiet -- so quiet that some classmates of his say they never heard his voice in three years. His roommates reported he was distant and private, eating by himself night after night, and watching wrestling on TV.

Cho's roommates say he obsessively downloaded music from the Internet. One of his favorites was the song "Shine," by Collective Soul, which he played over and over

He even scribbled some of the lyrics on the wall, they said -- lyrics like, "Teach me how to speak; Teach me how to share; Teach me where to go."

He was early to bed and early to rise, normally in bed by 9 p.m., and sometimes up by 5:30 the next morning. His roommates tell ABC News they would see him in the morning putting in his contact lenses, taking prescription medication and applying acne medicine to his face.

"He pretty much never talked at all," said Joseph Aust, who shared a bedroom with him in a six-person dorm suite in Harper Hall. "I tried to make conversation with him earlier in the year. He gave one-word answers.

"He pretty much never looked me in the eye," Aust said.

In recent weeks his routine had changed. His roommates say he went to the campus gym at night, lifting weights to bulk up. He went for a haircut -- surprising them by coming back to the room with a military-style buzz cut.

Aust and another roommate, Karan Grewal, say they were aware that Cho had pursued women on campus. They said he also seemed to have an imaginary girlfriend, a supermodel named "Jelly."

Students say he seemed as quiet as ever in the days before Monday's rampage.

Trey Perkins, a student who saw Cho during the shooting spree, said it was unreal, "being that close to a monster."

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[outofhere]

Psychiatrists can't read people's minds, and they can't predict the future either. All this hoopla about Cho's hospitalization only tells us that AT THE TIME of the evaluation, in 2005, Cho was deemed not danger to self or others. AT THE TIME. Seems like he changed his mind since then... But psychiatrists can't be held responsible for things like this, psychiatrists can be held liable IF danger to self/others were not considered and evaluated. There is the Tarasoff: if a psychiatrist finds that a patient is having thoughts of harming a SPECIFIC person, it is his/her DUTY to warn. But that doesn't seem to the case at the moment.

Cases like these make me concerned about mental health care overall. I treated a graduate student who was referred to student mental health because he had sent inappropriate e mails to another graduate student- and the female student felt she was being stalked. I thought my patient had Asperger's Syndrome, not a danger to himself or others. AT THE TIME. God willing, he won't change his mind...

This is a HORRIBLE tragedy... I have no insightful solution for this, or thousand others who do kill themselves and harm others, either due to Axis I or II dx. Maybe just this then: don't be discouraged from becoming a psychiatrist because you can't predict the future, and remember, there are only two kinds of psychiatrists: ones who have not had one's patients suicide, and those that have had patients who suicide. AND, the world needs more psychiatrists for improved access. There is much work to be done...

 

[Encephalopathy]

So...is it inappropriate to speculate on a diagnosis? Religious delusions, social withdrawal, flat affect - schizophrenia, paranoid-type?

 

[whopper]

I've been trying to figure out a dx but there's not enough information.

E.g. I can't tell if his strange paranoid rant on NBC was out of anger or psychotic paranoia. It'd be too premature in my opinion for a doctor to declare they got his diagnosis unless they've actually interviewed the guy. As we all know an initial interview only is best educated hypothesis, and only constant observation for at least days gives close to accurate diagnosis.

I don't think anyone should be faulting the mental facility at this point either. Remember the commitment laws that we are supposed to obey. If Cho wasn't dangerous at that moment and couldn't be seen to be so for the immediate future you're supposed to let them go, even if you think they are mentally ill.

If anything I think this incident will yield more power to psychiatrists and doctors for commitment. I don't know if that is a good thing either because I've seen too many lazy doctors commit on a moment's notice.

 

[OldPsychDoc]

So does this say more about the mental health system, or about laws which allow anyone with two forms of ID to buy deadly weapons and ammunition?

 

[tennreb]

So does this say more about the mental health system, or about laws which allow anyone with two forms of ID to buy deadly weapons and ammunition?

Gun control will just take guns out the hands of law-abiding citizens and put them in the hands of criminals like this guy. If more people in the area had exercised their right to carry a handgun, then many lives would have been saved .

 

[OldPsychDoc]

Gun control will just take guns out the hands of law-abiding citizens and put them in the hands of criminals like this guy. If more people in the area had exercised their right to carry a handgun, then many lives would have been saved .

Uhhh---Wrong.

This kid killed 32 people and himself with a legally purchased handgun.
The most rudimentary screening for past legal history and mental fitness to own a gun would have stopped the guy. However, such measures are anathema to the NRA lobby--who should at least be sharing the blame with the local mental health system.

I promise I will not respond to any further temptations to take this thread further off topic--though I suppose it could rightly be asked how comfortable you are with your patients' exercising their 2nd amendment rights.... Sorry.

 

[Chewbacca Jung]

Gun control will just take guns out the hands of law-abiding citizens and put them in the hands of criminals like this guy. If more people in the area had exercised their right to carry a handgun, then many lives would have been saved .

let's see...
how many gun related deaths are there in Canada per year? --4.3/100,000, with about 1 gun per 4 people.
And how many in the U.S.? --11.4/100,000, with .82 guns per person


So... your answer to gun violence is to have everyone packing heat?


Perhaps a hand gun in the right hands could have adverted disaster at VT. But I think that the adverse effect of having everyone armed in the U.S. would wreck havoc on our death rate. As national gun related deaths are proportional to the gun/population ratio (even controlling for numerous potentially confounding factors).

Here's some random, nice, though I'd admit slightly biased sites that shows a lot of fun statistics:
CBC
Coalition for gun control

 

[Hurricane]

There is the Tarasoff: if a psychiatrist finds that a patient is having thoughts of harming a SPECIFIC person, it is his/her DUTY to warn. But that doesn't seem to the case at the moment.

Yes, due to the increased sensitivity surrounding these issues, I have to call a drug dealer named "Big Stu" and give a Tarasoff warning, about a guy who has no axis I disorder other than cocaine abuse. I sure as hell ain't using my cell phone for that one.

 

[Solideliquid]

Yes, due to the increased sensitivity surrounding these issues, I have to call a drug dealer named "Big Stu" and give a Tarasoff warning, about a guy who has no axis I disorder other than cocaine abuse. I sure as hell ain't using my cell phone for that one.

Dude. *67 for the win.

As for the above, it would have helped if during a background check you could see that someone has been admitted to a mental hospital. But wouldn't that violate HIPPA to release that kind of info? And on the other hand, this is an isolated event, tough gun control laws won't really curtail crime-related gun violence. I don't really see any way that anyone could have seen this coming or avoided this. Sure you can say gun laws, but he could have just gotten a gun elsewhere. Sure you can say the school should have watched him, but what were they supposed to do lock him in a dorm and conduct class over his computer? Kick him out of school?

I don't think anyone recognized this kid needed long term care, heck even the psychiatrist in 2005 didn't think he was a danger to self. Of course in 05 his presentation might not have been this bad. Seems like if he was schizophrenic he was in prodrome in 05 and was "ramping up" to the events that unfolded this week.

So sad, my prayers are with the families.

 

[theramofreason]

Why is this a gun control issue? A handgun purchase does require a waiting period and a criminal background check for felonies. He purchased at least one of the guns over a month ago, so this was a well-thought out plan. He could have just as easily planned to poison the food in the cafeteria or use a poisonous gas in a dorm ventilation system.

The OKC bombing didn't (and shouldn't have) led to the ban of farm fertilizer.

The mass suicide of the Jim Jones cult didn't (and shouldn't have) lead to legislation to end Kool-Aid sales.

This massacre, while tragic, should be used as a way to promote mental health advocacy in this country. The media has dug through this guy's past looking for warning signs, which is a good start. What we should be seeing are psychiatrists and reporters warning the public that if someone they know shows any of these behavior patterns, it could be a sign of a mental illness and it's OKAY to seek help.

 

[Hurricane]

As for the above, it would have helped if during a background check you could see that someone has been admitted to a mental hospital. But wouldn't that violate HIPPA to release that kind of info?

Well, at the moment having a mental illness isn't considered a crime, thus court comittments, mental illness warrants, orders of protective custody, etc do not appear on one's criminal record. Nor should they IMO. Whether or not they should appear on a more extensive background check is another matter.

I wonder, since these documents are filed with the court, are they then considered public record? Or are mental illness courts sealed or confidential in some way, kinda like juvenile records? It does seem like kind of a privacy violation to have your psych eval out there in the public domain without your consent.

 

[f_w]

Sad as it is, this case illustrates a couple of issues:

- Often, colleges seem to be pretty heavy handed when it comes to mental health. People get kicked out of colleges all the time for rather 'benign' mental health issues (problems that only affect them personally, no issues of danger to others). This event will certainly make it harder for college students with any kind of mental health issues to keep their shot at a career.

- A creep is a creep is a creep. Somehow he managed to make lots of people around him pretty uncomfortable for a very long time. Unfortunately, being a creepy loner is neither a crime, nor a diagnosis.

- If someone stalks you, get a protective order. It might not help you (they rarely do), but it creates a paper trail that might help someone else down the line.

- 'I only did my job', 'we acted on the information we had at the time' and ' it is an act of god' allways come up when another head got bashed in with a hammer.

- He should have studied engineering. With his personality he wouldn't have stood out as much as in the 'creative writing' environment of his english major. (he would have made a good IT support person, I am sure)

 

[deleted113029]

Hey everyone. I wanted to talk about the VT tragedy in a psych forum after seeing the enormous amount of media coverage on the mass murderer. I have heard mostly ignorant thoughts on this matter across all media channels about how the murderer was a cold-hearted killer with a simple jealous vengeful mentality towards his peers.

(I thoroughly enjoyed psych during my clinical year and learned a lot about mental illness and neuropathology.) My thoughts are on how media portrays mental illness as laughable in the context of this mass killing and that the only possible explanation is that he was a criminal who knew what he was doing. Many interviewers have NO experience with schizophrenia, cluster A and B personality disorders, etc. YET they speak as if they are experts by strongly voicing their opinion. (This can only cause ignorance about mental illness to perpetuate in our society since most of America feeds off of their TV's.) They quickly dismiss the killer's behavior and lack of speech as "weird" and that it has been happening for years. This guy had alogia, asociality, persecutory and religious delusions to name a few yet they invariably say,"this guy was just odd" instead of it being a natural progression of an untreated mental illness coming to its fruition.

I just need to vent here because i thought you guys would understand my frustration with how the media without a medical education can freely speak about something WAY over their heads. am i alone? if so, i apologize for my rant and good luck to your futures.

 

[Adam_K]

let's see...
how many gun related deaths are there in Canada per year? --4.3/100,000, with about 1 gun per 4 people.
And how many in the U.S.? --11.4/100,000, with .82 guns per person

I'd argue that this can just as easily be ascribed to a significantly different history and demographics.

So... your answer to gun violence is to have everyone packing heat?

But I think that the adverse effect of having everyone armed in the U.S. would wreck havoc on our death rate. As national gun related deaths are proportional to the gun/population ratio (even controlling for numerous potentially confounding factors).

Well, guns are banned in DC. On top of that, DC has one of the highest police per capita numbers in the nation along with the highest murder and crime rates.

On the other hand, New Hampshire has very high gun ownership and is among the safest states in terms of crime.

The Brady Campaign (pro gun control) gives New Hampshire a D- for its laws. Tellingly, it does not appear to list DC's report card.

So, apart from population, history and demographics, what is the difference between New Hampshire and DC?

Population density. NH's population density is 125/sq mile, while DC's is 9,015/sq mile.

Perhaps a hand gun in the right hands could have adverted disaster at VT.

The point is that law abiding citizens didn't have access to their guns at VT, while criminals don't seem to be bothered with the finer points of the law.

 

[Adam_K]

Uhhh---Wrong.

This kid killed 32 people and himself with a legally purchased handgun.
The most rudimentary screening for past legal history and mental fitness to own a gun would have stopped the guy. However, such measures are anathema to the NRA lobby--who should at least be sharing the blame with the local mental health system.

Actually, they ran his record for felonies. He came up clear. What do you propose to do with mental health records? Make them public records?

I promise I will not respond to any further temptations to take this thread further off topic--though I suppose it could rightly be asked how comfortable you are with your patients' exercising their 2nd amendment rights.... Sorry.

Point taken. But, how do you propose (short of a blanket ban that leaves guns in the hands in criminals and law abiding folks unable to defend themselves) to screen for mental illness?

 

[whopper]

- 'I only did my job', 'we acted on the information we had at the time' and ' it is an act of god' allways come up when another head got bashed in with a hammer.

Problem sir is that if commit a patient, that is not dangerous, even if you believe they are mentally ill you are violating their Constitutional rights.

"I only did my job" is what a doc is often supposed to do and have taken an oath to do so.

I can't keep someone incarcerated against their will out of some paternalistic sense of duty. There's a fine line between good intentions and facism. If I can't garauntee safety, the state laws only allow me 24 hrs of time to play detective and try to fish through all the available data, and use up every available contact (call their families, their primary care doctor etc) and if I can't find anything of substance in those 24 hrs I have to let that patient go. Imagine getting a guy in the crisis center over the weekend when most available outlets of data are closed?

Also, if this guy was mentally ill in a psychotic sense (and we're not certain of that yet), the decline is gradual. Its only when the crap hits the fan that most people are willing to dx a patient with a psychotic illness and commit. This is done to protect people's rights and prevent unneeded commitments.

 

[Chewbacca Jung]

I'd argue that this can just as easily be ascribed to a significantly different history and demographics.



Well, guns are banned in DC. On top of that, DC has one of the highest police per capita numbers in the nation along with the highest murder and crime rates.

On the other hand, New Hampshire has very high gun ownership and is among the safest states in terms of crime.

The Brady Campaign (pro gun control) gives New Hampshire a D- for its laws. Tellingly, it does not appear to list DC's report card.

So, apart from population, history and demographics, what is the difference between New Hampshire and DC?

Population density. NH's population density is 125/sq mile, while DC's is 9,015/sq mile.



The point is that law abiding citizens didn't have access to their guns at VT, while criminals don't seem to be bothered with the finer points of the law.

I am responding to the quote that (and i paraphrase) 'if more people had exercised their 2nd amendment rights, the outcome of this tragedy could have been everted.'

My conclusion, more guns does not equal less violence.

If you want to debunk those statistics, use comparable data. I said nothing about gun laws. I gave guns/population stats, and at a national level (averaging uban/rural gun violence rates, to some extent). Any statistics comparing New Hampshire and D.C., are confounded by rural/urban demographics. I'd still be interested in seeing the actual gun/pop ratio of New Hampshire and D.C., though, it could be telling.

anyway, I realize that my stats were pretty one- dimensional, but I was proving a specific argument.

My main driving point is that most arguments for increased use of weapons is anecdotal, and do not rely on careful population-controlled data. In fact, because of this incident, more people may actually exercise their increase the use of their 2nd amendment rights and start packing heat. That could cause an increase in gun related deaths (many of them being incidental). If you were interested in proving or disproving this theory, now would be a good time to watch gun carrying rates and gun related death rates climb or fall-- for those of you sociologically inclined, anyway...

 

[Adam_K]

I am responding to the quote that (and i paraphrase) 'if more people had exercised their 2nd amendment rights, the outcome of this tragedy could have been everted.'

My conclusion, more guns does not equal less violence.

If you want to debunk those statistics, use comparable data. I said nothing about gun laws. I gave guns/population stats, and at a national level (averaging uban/rural gun violence rates, to some extent). Any statistics comparing New Hampshire and D.C., are confounded by rural/urban demographics. I'd still be interested in seeing the actual gun/pop ratio of New Hampshire and D.C., though, it could be telling.

anyway, I realize that my stats were pretty one- dimensional, but I was proving a specific argument.

My main driving point is that most arguments for increased use of weapons is anecdotal, and do not rely on careful population-controlled data.

I understand your point, but the theoretical number of guns owned by civilians in DC (after 1977) should be zero, right?

Despite this, the firearms death rate for DC is 31.2 per 100,000. (New Hampshire's is 5.8) Source: http://www.statemaster.com/graph/cri_mur_wit_fir-death-rate-per-100-000

Now, that's hardly anecdotal is it?

 

[f_w]

Problem sir is that if commit a patient, that is not dangerous, even if you believe they are mentally ill you are violating their Constitutional rights.
.
.
.
This is done to protect people's rights and prevent unneeded commitments.

I am aware of that conflict, and I certainly don't fault any particular professional involved in this guys care with letting him go. While I believe that there is probably a psychiatric background to his behaviour, the question on how to deal with him as a college student falls more with the college rather than the behavioural health system.

The problem I have is that this didn't happen 'out of the blue'. Several people along the way noticed his conflicted and potentially violent streaks. Female students had complained about stalking behaviour, faculty was concerned about his violent phantasies. Somewhere along the way there would have been an opportunity to convene some sort of multidisciplinary conference and come up with a risk assessment for him (from a administrative/legal bend, not so much a psychiatric assessment).

And yes, I am glad they repealed the Assault weapons ban. The fact that 13 and 17 round magazines for handguns have become available again for over the counter new sales is certainly a blessing.

 

[whopper]

The problem I have is that this didn't happen 'out of the blue'. Several people along the way noticed his conflicted and potentially violent streaks. Female students had complained about stalking behaviour, faculty was concerned about his violent phantasies. Somewhere along the way there would have been an opportunity to convene some sort of multidisciplinary conference and come up with a risk assessment for him (from a administrative/legal bend, not so much a psychiatric assessment).

True, but in each instance the mechanism to commit or charge the guy could've been followed but was not done.

The stalked females didn't press charges. Who can blame them? That's a pain in the butt and who could've known?

The guy definitely had red flags, but it seems IMHO that the real thing that could've caught this thing for real is if the gov had access to this guy's medical records. As we all know the gov can't do that, and we wouldn't want them to have that access. We wouldn't want the college prying into a person's private medical records either.

ACtually if the gov did keep track of people's medical records and allowed prosecutors to have them--it would actually greatly diminish a lot of hospital related fraud such as malingering and such. However the assault on privacy would not allow the public nor our lawmakers to allow such a provision.

I'm thinking this is one of those things that we have to pay to have a free society. Someone please prove me wrong because sometime in the next 10 years this thing is going to happen again.

 

[Chewbacca Jung]

I understand your point, but the theoretical number of guns owned by civilians in DC (after 1977) should be zero, right?

Despite this, the firearms death rate for DC is 31.2 per 100,000. (New Hampshire's is 5.8) Source: http://www.statemaster.com/graph/cri_mur_wit_fir-death-rate-per-100-000

Now, that's hardly anecdotal is it?

How is there even a firearms death rate in D.C. if nobody has any fire arms?

 

[Psychintern2006]

MDD with flat affect discharged on out patient commitment-seems like a decent discharge plan-but not sure why was his ED not filed again if he was not following his commitment/ treament plan- by the case worker.



Va. Tech Killer Ruled Mentally Ill by court; Let Go After Hospital Visit
Cho Had Harassed Two Female Students; Officials Concerned He Was Suicidal
By NED POTTER and DAVID SCHOETZ

April 18, 2007 — - A court found that Virginia Tech killer Seung-Hui Cho was "mentally ill" and potentially dangerous. Then it let him go.

In December 2005 -- more than a year before Monday's mass shootings -- a district court in Montgomery County, Va., ruled that Cho presented "an imminent danger to self or others." That was the necessary criterion for a detention order, so that Cho, who had been accused of stalking by two female schoolmates, could be evaluated by a state doctor and ordered to undergo outpatient care.

According to the "Temporary Detention Order" obtained by ABC News, psychologist Roy Crouse found Cho's "affect is flat and mood is depressed.

"He denies suicidal ideation. He does not acknowledge symptoms of a thought disorder," Dr. Crouse wrote. "His insight and judgment are normal."

That information came to light two days after Cho, a Virginia Tech senior, killed 32 people and then himself in a shooting rampage on the university's campus.


'An Imminent Danger to Himself'

The evaluation came from a psychiatric hospital near Virginia Tech, where Cho was taken by police in December 2005, after two female schoolmates said they received threatening messages from him, and police and school officials became concerned that he might be suicidal.

After Dr. Crouse's psychological evaluation of Cho, Special Justice Paul M. Barnett certified the finding, ordering followup treatment on an outpatient basis.

On the form, a box is checked, showing that Cho "presents an imminent danger to himself as a result of mental illness."

Immediately below it was another box that is not checked: "Presents an imminent danger to others as a result of mental illness."

Authorities said they had no contact with Cho between then and Monday's mass killings.


Package Sent to News Media

This afternoon, NBC received a package they believe was sent to the network by Cho. The package includes photographs of Cho holding firearms, as well as a DVD with video and a letter running several pages long.

One of the pictures shows Cho menacingly wielding a hammer. It bears a striking rememblance to a 2003 South Korean film, "Oldboy." The film, an international hit, explores themes of revenge and incest -- themes also apparent in plays Cho had written as a student. However, it is not known if Cho had seen "Oldboy."

The letter received by NBC News is described as angry and rambling---expressing hatred for rich people and elitists. It is described as very similar to the letter discovered in the Cho's dorm room. According to NBC news, it states "this did not have to happen."

The package was mailed at 9:01 a.m. Monday morning at a Blacksburg, Va post office, sources said. Cho allegedly put the package in the hands of a female clerk before leaving. The clerk told us a little while ago she remember seeing Cho and recalls having to look up the zipcode for New York City's Rockefeller Plaza.

It appears that the suspect took the time to mail a package in between his shooting spree---showing a degree of cold-blooded planning.


Sent to Psychiatric Hospital

Police obtained the 2005 detention order from a local magistrate after it was determined by a state-certified employee that Cho's apparent mental state met the threshold for the temporary detention order.

Under Virginia law, "A magistrate has the authority to issue a detention order upon a finding that a person is mentally ill and in need of hospitalization or treatment.


Wendell Flinchum, the chief of the Virginia Tech police department, said that it's common for university police to work with state-affiliated mental health facilities instead of on-campus counseling because it is easier to obtain a detention order.

"We normally go through access [appealing to the state's legal system for help] because they have the power to commit people if they need to be committed," Flinchum said at a press conference Wednesday morning.

Cho was taken to Carilion St. Albans Behavioral Health Center in Radford, Va., a private facility that can take 162 inpatients, according to court documents.

It's unclear whether Cho went to the hospital with police on his own or was taken there under protective custody, a possibility under the temporary detention order obtained by police.

One of the young women complained in November 2005 that Cho, then 21, was stalking her, but she declined to press legal charges against him. Police interviewed Cho for the first time and referred the case to the school's internal disciplinary board.

It's unclear whether any action was ever taken by the school, although Edward Spencer, a school vice president, said that it's not uncommon for a complaint never to reach a full hearing.

A second woman student, less than two weeks later, told authorities she received disturbing instant messages from Cho, and asked police to make sure there was "no further contact" from him.

Police spoke to Cho the next day. They say that shortly after, they received a call from an acquaintance of his, expressing concerns that he might be suicidal.

For a third time, police met with him. "Out of concern for Cho, officers asked him to speak to a counselor," Flinchum said. "He went voluntarily to the police department."

The student complaints that brought Cho to the attention of authorities came during the same time that creative writing professor Lucinda Roy went to administrators to voice her concern about violent themes in Cho's writing.

Roy told ABC News that Cho seemed "extraordinarily lonely -- the loneliest person I have ever met in my life."

While the school, citing privacy laws, did not conclusively say that school counselors had ever worked with Cho, they did say that a system for working with outside mental health agencies and local authorities is in place.

"Clearly, mental health professionals have a legal and moral responsibility," when a student presents a possible risk, said Christopher Flynn, head of the university's counseling center. "We have a duty to warn."

But Flynn also said that signs of trouble in Cho's behavior were not a clear indicator that action would follow. "It is very difficult to predict when what someone perceives as stalking, is stalking."


A Loner, Mysterious Even to His Roommates

Seung Cho was quiet -- so quiet that some classmates of his say they never heard his voice in three years. His roommates reported he was distant and private, eating by himself night after night, and watching wrestling on TV.

Cho's roommates say he obsessively downloaded music from the Internet. One of his favorites was the song "Shine," by Collective Soul, which he played over and over

He was early to bed and early to rise, normally in bed by 9 p.m., and sometimes up by 5:30 the next morning. His roommates tell ABC News they would see him in the morning putting in his contact lenses, taking prescription medication and applying acne medicine to his face.

"He pretty much never talked at all," said Joseph Aust, who shared a bedroom with him in a six-person dorm suite in Harper Hall. "I tried to make conversation with him earlier in the year. He gave one-word answers."

"He pretty much never looked me in the eye," Aust said.

In recent weeks his routine had changed. His roommates say he went to the campus gym at night, lifting weights to bulk up. He went for a haircut -- surprising them by coming back to the room with a military-style buzz cut.

Aust and another roommate, Karan Grewal, say they were aware that Cho had pursued women on campus. They said he also seemed to have an imaginary girlfriend, a supermodel named "Jelly."

Students say he seemed as quiet as ever in the days before Monday's rampage.

Trey Perkins, a student who saw Cho during the shooting spree, said it was unreal, "being that close to a monster."


Copyright © 2007 ABC News Internet Ventures

 

[Chewbacca Jung]

I am aware of that conflict, and I certainly don't fault any particular professional involved in this guys care with letting him go. While I believe that there is probably a psychiatric background to his behaviour, the question on how to deal with him as a college student falls more with the college rather than the behavioural health system.

The problem I have is that this didn't happen 'out of the blue'. Several people along the way noticed his conflicted and potentially violent streaks. Female students had complained about stalking behaviour, faculty was concerned about his violent phantasies. Somewhere along the way there would have been an opportunity to convene some sort of multidisciplinary conference and come up with a risk assessment for him (from a administrative/legal bend, not so much a psychiatric assessment).

And yes, I am glad they repealed the Assault weapons ban. The fact that 13 and 17 round magazines for handguns have become available again for over the counter new sales is certainly a blessing.

I think part of the problem revolves around the issues of form and content. Form being the classical presentation of the disease, and content being the specific behavioral manifestations of the disorder which may or maynot be congruent with the classical presentation. The criterea for commitment is based on form, while someone going postal is content. Form is based on population data and experience, and is basically what is in the DSM and other treatment guidlines. Content will almost always suprise you. It's completely unrealistic and unfair to assess someone's clinical judgement of both form and content on the same level, as the popular press is doing.

 

[tennreb]

Uhhh---Wrong.

This kid killed 32 people and himself with a legally purchased handgun.
The most rudimentary screening for past legal history and mental fitness to own a gun would have stopped the guy. However, such measures are anathema to the NRA lobby--who should at least be sharing the blame with the local mental health system.

I promise I will not respond to any further temptations to take this thread further off topic--though I suppose it could rightly be asked how comfortable you are with your patients' exercising their 2nd amendment rights.... Sorry.

There are 250 million guns in the United States. Do you know how long it would take me to illegally buy a gun? About 30 minutes. I imagine it would have taken this guy a little longer since he was in a small town, but I bet he could have done it in half a day at most. Considering that this was very well planned, it wouldn't have been a problem for him. On the other hand, if we had more guns in the hands of responsible citizens, then tragedies like this would be less likely.

 

[Doctor Bagel]

There are 250 million guns in the United States. Do you know how long it would take me to illegally buy a gun? About 30 minutes. I imagine it would have taken this guy a little longer since he was in a small town, but I bet he could have done it in half a day at most. Considering that this was very well planned, it wouldn't have been a problem for him. On the other hand, if we had more guns in the hands of responsible citizens, then tragedies like this would be less likely.

But there are 250 million guns in the US just because we have lax gun control. Also, again, if having a gun is such a great universal defense, why didn't it help here, and why doesn't it generally ever help? We have tons of armed law-abiding citizens, and yet that's failed to reduce crime rates.

Anyway, getting back to the point of the thread, I'm with f_w in being concerned with how mentally ill students are going to be treated going forward. We already discussed that George Washington U. case here where the school brought disciplinary action against a student for seeking treatment for suicidal ideation. Are schools going to look for ways to just kick out the mentally ill students instead of having to deal with threats like this?

 

[f_w]

The stalked females didn't press charges. Who can blame them? That's a pain in the butt and who could've known?

Yes it is a PITA, and given the workload of most court systems, chances are there wouldn't have been any type of criminal conviction based on this. However, it is easier for the university to dismiss a student once the restraining orders start piling up.

We wouldn't want the college prying into a person's private medical records either.

Private colleges pretty much have access to mental health and criminal records. They suspend and expel students all the time after they have either run-ins with the law or contact with the mental health system (particularly after episodes of suicidality).

Bottom line:
Psych diagnosis or not, once a student has made documented threats against other students, he should be kicked out.

Btw:

Rampage killings are not unique to the US. About 10 years ago, a guy in the UK killed a dozen school kids or so. Also, a couple of years ago, a high-school senior in germany went on a shooting rampage (he had enough patience to wait out the 1 year 'cool-down' period before purchasing a handgun in that country).

 

[Hernandez]

So does this say more about the mental health system, or about laws which allow anyone with two forms of ID to buy deadly weapons and ammunition?

Actually, the media is incorrect on this issue. It is against the law in 47 states (including Virginia) for those with mental illness to purchase firearms and it's against federal law (title 18 922 (g)(4)). The problem is that the instant background check system used to purchase firearms has no access to a database of those with potentially violent illness. So he may not have been denied when he bought the firearm, but as I understand the law, this was not a "legal" purchase.

A person who answers "yes" to any of the below questions may be prohibited from purchasing or possessing a firearm pursuant to state and/or federal law.

9. Have you ever been adjudicated legally incompetent, mentally incapacitated, or been involuntarily committed to a mental institution?​

But there are 250 million guns in the US just because we have lax gun control. Also, again, if having a gun is such a great universal defense, why didn't it help here, and why doesn't it generally ever help? We have tons of armed law-abiding citizens, and yet that's failed to reduce crime rates.

The problem with your post here is you're looking at it wrong. Armed law abiding citizens may not reduce crime, but feel free to try and find any proof that they increase it. In fact the Department of Justice did a study in 1996 which shows that firearms are used 1,500,000 times a year to defend from harm/prevent crime/etc.

 

[lilzelda]

Its a sad story, this kid needed help but had no one around him to really force him to get help. I can't feel anything right now than to be totally mad at the mental health system and society. He's taking pictures of people in class, writing crazy stories, doesn't talk to anyone, wants to commit suicide and stalks people. I mean really. Whats even more depressing is the media's portrayl of this kid as a cold blooded murder, instead of looking at what could of been done to prevent this.

 

[RustNeverSleeps]

I just need to vent here because i thought you guys would understand my frustration with how the media without a medical education can freely speak about something WAY over their heads. am i alone? if so, i apologize for my rant and good luck to your futures.

Totally agree. It really bothers me to see the media talk about this with their "experts" who are not in a medical/psychological field. Talk about misinforming people.

 

[yourmomma]

Hey everyone. I wanted to talk about the VT tragedy in a psych forum after seeing the enormous amount of media coverage on the mass murderer. I have heard mostly ignorant thoughts on this matter across all media channels about how the murderer was a cold-hearted killer with a simple jealous vengeful mentality towards his peers.

(I thoroughly enjoyed psych during my clinical year and learned a lot about mental illness and neuropathology.) My thoughts are on how media portrays mental illness as laughable in the context of this mass killing and that the only possible explanation is that he was a criminal who knew what he was doing. Many interviewers have NO experience with schizophrenia, cluster A and B personality disorders, etc. YET they speak as if they are experts by strongly voicing their opinion. (This can only cause ignorance about mental illness to perpetuate in our society since most of America feeds off of their TV's.) They quickly dismiss the killer's behavior and lack of speech as "weird" and that it has been happening for years. This guy had alogia, asociality, persecutory and religious delusions to name a few yet they invariably say,"this guy was just odd" instead of it being a natural progression of an untreated mental illness coming to its fruition.

I just need to vent here because i thought you guys would understand my frustration with how the media without a medical education can freely speak about something WAY over their heads. am i alone? if so, i apologize for my rant and good luck to your futures.

i have to say that i respectfully disagree with the general sentiment here. does the media really know what they're talking about with regards to mental illness? probably not. and i certainly don't pretend to have insight that no one else does...

but what makes me more fearful than people not getting treatment for mental health is society thinking that people with mental illness go around on killing rampages. now that's a stigma, and talk about something that will truly keep the sick from seeking help and wearing a diagnosis.

could this kid have had a mental health problem that contributed to this in some way? of course it's possible. but was it strictly causal? if you answer "yes," are you sure? why did he do this and the thousands of other untreated schizophrenic/bipolar patients have not? maybe they're all ticking time bombs...

or, maybe he's just a bad, mean person. (and don't tell me that they don't exist.) that's the way it looks to me. one way or another, he would have found a path to fulfill his fantasy. he chose to be what he is. listen to the kid's video - he wanted us to believe that we as a society drove him to this.

so you can either trust the guy who just blasted 33 people for no god damn reason, or you can trust the basic intuition that says the guy did not have an ounce of heart in his body. if someone on tv wants to call him a cold-blooded murderer, that's fine by me.

(and believe it or not, i'm actually a bleeding-heart liberal - don't get me wrong, i think his life is tragic, but i also think that this has roughly zero to do with mental illness.)

 

[Quynh2007]

hi, this is my first post here (since halflife came over to the psych board), and I'm still a baby in the psych world, so please bear with me.

this may be the wrong thread to post in but an idea i've been toying with lately in regards to this situation is whether or not there's enough services and awareness for asian and international students at universities and colleges. I know at my school, I've been told over and over that the asian population generally has high rates of mental problems, but the lowest in terms of seeking help. Furthermore, at my school, a large majority of suicides have been international students (esp. asians) who may feel isolated, out of place, etc. on top of the stressors of life.

With the looming stereotype of "model minority," and Asians tendencies to have internalizing problems, AND on top of all that, the stigma of seeking psychological help, it makes it even harder for professors/friends/RAs to spot students who may need assistance or to watch out for. I guess my question is what is there that can be done? am i totally wrong, just talking nonsense?

anyway i have no clue, just rambling what's been swirling in my head. I'm just graduating from undergrad this coming May and heading to a clinical psych program come fall, so i have a long time to think about it and touch on it as I mature as a psychologist.

 

[paramour]

hi, this is my first post here (since halflife came over to the psych board), and I'm still a baby in the psych world, so please bear with me.

this may be the wrong thread to post in but an idea i've been toying with lately in regards to this situation is whether or not there's enough services and awareness for asian and international students at universities and colleges. I know at my school, I've been told over and over that the asian population generally has high rates of mental problems, but the lowest in terms of seeking help. Furthermore, at my school, a large majority of suicides have been international students (esp. asians) who may feel isolated, out of place, etc. on top of the stressors of life.

With the looming stereotype of "model minority," and Asians tendencies to have internalizing problems, AND on top of all that, the stigma of seeking psychological help, it makes it even harder for professors/friends/RAs to spot students who may need assistance or to watch out for. I guess my question is what is there that can be done? am i totally wrong, just talking nonsense?

anyway i have no clue, just rambling what's been swirling in my head. I'm just graduating from undergrad this coming May and heading to a clinical psych program come fall, so i have a long time to think about it and touch on it as I mature as a psychologist.

I was actually talking about something semi-related with another individual a few days ago.

People were commenting about the potential backlash on the Asian population at VT and how they would all be stereotyped as mass murderers. Yet, Asians in some countries actually have higher suicide rates than the States, so why didn't this particular individual just shoot himself and be done with it? Why did he opt to kill a substantial number of people before killing himself? Could it be that OUR highly individualistic culture took its toll on him? He started to believe that he has to think about himself alone rather than other individuals in the collective group. At the same time, his ingrained Asian traditions may have prevented him from seeking help with his inability to integrate, if you will, the two with one another . . . which led him to commit the crimes under discussion. What better way to draw attention to one's self than killing a large number of people? Perhaps we should be spending more effort on multiculturalism and its effect on mental health, particularly when these individuals are being exposed to a number of norms from differing cultures simultaneously.

Just a thought, albeit a likely semi-incoherent one at this time o' the morning.

 

[Adam_K]

How is there even a firearms death rate in D.C. if nobody has any fire arms?

My point was to show how ineffectual gun control laws are.

Back to your point about guns and population. Ignoring the cultural component I raised initially, there is the example of Switzerland.

According to liberal estimates, there are 3 million guns in circulation in Switzerland for a population of about 7.5 million.

The plurality (if not majority) of these weapons are assault rifles.

But, if we look at murders with firearms per capita...

http://www.nationmaster.com/graph/cri_mur_wit_fir_percap-crime-murders-firearms-per-capita

We find Switzerland beating Canada by a smidgen in 19th place.

So, obviously, it is not just the guns/population.

Now as far as rare psychotic mass murders go, they take place whether there are lots of guns in circulation, gun control or not.

http://archives.cnn.com/2001/WORLD/europe/09/27/switzerland.shooting/
http://en.wikipedia.org/wiki/Dunblane_Massacre
http://en.wikipedia.org/wiki/Montreal_massacre

 

[Adam_K]

Is anyone else as shocked as I am that NBC aired the videos?

Here is some of the best coverage I've seen on that subject.

http://abcnews.go.com/GMA/print?id=3056168

Psychiatrist: Showing Video Is 'Social Catastrophe'
Mental Health Expert Says Shooter Was Trying to Attempt Immortality; Showing Clips Validates His Delusions

April 19, 2007 — - The videos of Seung-hui Cho, the man who fatally shot 32 people at Virginia Tech on Monday and then killed himself, shouldn't have been released because they don't offer the public any greater understanding of the gruesome crime, said Michael Welner, a forensic psychiatrist and ABC News consultant, on "Good Morning America" today.

"If anybody cares about the victims in Blacksburg and if anybody cares about their children, stop showing this video now. Take it off the Internet. Let it be relegated to YouTube," Welner said. "This is a social catastrophe. Showing the video is a social catastrophe."

During a pause in his killing spree Monday, Cho sent a package that included 43 photos, video clips and a letter to NBC. NBC received the package Wednesday.

The videos included Cho's rants on the reasoning behind the crimes he was presumably about to commit.

"Do you know what it feels like to be torched alive? Do you know what it feels like to be humiliated and impaled on a cross and left to bleed to death for your amusement? You have never felt a single ounce of pain in your whole lives. You have vandalized my heart, raped my soul and torched my conscience," Cho said in the videos.

Welner believes that instead of offering insight, these videos merely offer validation of delusional behavior.

"I think that's very important for the viewing audience to understand. This is not him.These videos do not help us understand him. They distort him. He was meek. He was quiet. This is a PR tape of him trying to turn himself into a Quentin Tarantino character," Welner said. "This is precisely why this should not be released. Parents, you should cut the pictures out of the newspaper. Do not let your children see it. Take them out of the room when these videos are shown. Because he's paranoid and his agenda of blaming the rest of the world is unedited."

"There's nothing to learn from this except giving it validation. If this rambling showed up in an emergency room, my colleagues and I would listen carefully and, when we reflected that it was delusional, would go see the next patient and start the medication," he said. "This makes it sound like he was tormented. He wasn't."

Although the school and authorities have been criticized in recent days about reports of Cho's mental states and past run-ins with students, Welner said that unless someone appeared to be high risk there was little medical professionals could do.

"In an emergency room, again, unless someone is at high risk, then there's nothing you can do. [Cho] presented to mental health authorities. He's certainly capable of presenting himself quietly," Welner said.

Welner also said that he believed showing the video just gave fodder to people who were already isolated and disaffected.

"I promise you the disaffected will watch him the way they watched 'Natural Born Killers.' I know. I examine these people," he said. "I've examined mass shooters who have told me they've watched it 20 times. You cannot saturate the American public with this kind of message."

Welner maintained, however, that he was not blaming the media for airing the footage.

"It's not an issue of blame. It's an appeal. Please stop now. That's all," he said. "If you can take [talk show host Don] Imus off the air, you can certainly keep [Cho] from having his own morning show."

"They turn themselves into icons. They get articles written about themselves in The New York Times. This is perversion. We have to send a message to alienated people, you know what? You hate everybody around you? You're paranoid. You're sad. You're depressed. But these people are perverts," Welner said.

"They're … not powerful. He's a weak link. He needs to create and produce his own picture in order to give himself a sense of power. Nobody saw him that way. He didn't see himself that way and that's why he set this up and he did this to achieve immortality. We have to stop giving him that and we can do it now."

 

[Quynh2007]

I was actually talking about something semi-related with another individual a few days ago.

People were commenting about the potential backlash on the Asian population at VT and how they would all be stereotyped as mass murderers. Yet, Asians in some countries actually have higher suicide rates than the States, so why didn't this particular individual just shoot himself and be done with it? Why did he opt to kill a substantial number of people before killing himself? Could it be that OUR highly individualistic culture took its toll on him? He started to believe that he has to think about himself alone rather than other individuals in the collective group. At the same time, his ingrained Asian traditions may have prevented him from seeking help with his inability to integrate, if you will, the two with one another . . . which led him to commit the crimes under discussion. What better way to draw attention to one's self than killing a large number of people? Perhaps we should be spending more effort on multiculturalism and its effect on mental health, particularly when these individuals are being exposed to a number of norms from differing cultures simultaneously.

Just a thought, albeit a likely semi-incoherent one at this time o' the morning.

I've had this similar discussion w/my future advisor a couple of months ago since this is his area of interest/expertise.

I commented on how conflicted I often felt w/my motherland and the American traditions and culture (e.g. it took me until recently to even bear looking someone in the eye, a sign of disrepect in my culture, but a sign of honesty in the US), and he gave me a LOT of insight into Asian students and how American teachers/professors are not as aware of how Asian students tend to behave.

For him, he noticed that while Caucasians and other Americans tend to have blank stares when they don't get what the professor is teaching, Asian students tend to show absolutely no signs of confusion that would be a quick indicator of whether they are understanding the material or not. In turn, he had to change his teaching methods to compensate for this by asking questions in class for his students to answer to gauge their understanding.

 

[whopper]

http://www.mirror.co.uk/news/topsto...objectid=18931479&siteid=89520-name_page.html

Family is claiming he had autism.

 

[deleted113029]

i have to say that i respectfully disagree with the general sentiment here. does the media really know what they're talking about with regards to mental illness? probably not. and i certainly don't pretend to have insight that no one else does...

but what makes me more fearful than people not getting treatment for mental health is society thinking that people with mental illness go around on killing rampages. now that's a stigma, and talk about something that will truly keep the sick from seeking help and wearing a diagnosis.

could this kid have had a mental health problem that contributed to this in some way? of course it's possible. but was it strictly causal? if you answer "yes," are you sure? why did he do this and the thousands of other untreated schizophrenic/bipolar patients have not? maybe they're all ticking time bombs...

or, maybe he's just a bad, mean person. (and don't tell me that they don't exist.) that's the way it looks to me. one way or another, he would have found a path to fulfill his fantasy. he chose to be what he is. listen to the kid's video - he wanted us to believe that we as a society drove him to this.

so you can either trust the guy who just blasted 33 people for no god damn reason, or you can trust the basic intuition that says the guy did not have an ounce of heart in his body. if someone on tv wants to call him a cold-blooded murderer, that's fine by me.

(and believe it or not, i'm actually a bleeding-heart liberal - don't get me wrong, i think his life is tragic, but i also think that this has roughly zero to do with mental illness.)

Do you have any experience with forensic psychiatry? Ever seen a violent person with paranoid schizophrenia...let alone a person with a multiple murder conviction? Paranoid schizophrenia is a subtype of schizophrenia that is associated with a high level of function and VIOLENCE. His negative symptoms of alogia, asociality, affective flattening, along with positive Sx of obvious religious and persecutory delusions makes this boy have a poor prognosis especially in the context of absent psychiatric care.

Your saying his life being tragic has roughly zero to do with MI is uneducated at best. For example, ever hear theories on why people with antisocial personality disorder have an associated physical finding of bradycardia? i'll leave it up to you to explore that theory.

Anyway, i've seen some psychiatrists finally being interviewed on the media explaining their thoughts on the mentally ill killer. Mental illness is a real entity that needs to be addressed especially since it comprises 4 out of the top 10 illnesses with the highest global medical burden. Tell me this...how does one voluntarily go through life not saying much of anything EVEN as a child and then ramble on for 1800 words during his psychotic manifesto?

Have a great weekend!

 

[Quynh2007]

http://www.mirror.co.uk/news/topsto...objectid=18931479&siteid=89520-name_page.html

Family is claiming he had autism.

really? interesting...i find this hard to believe since he is an English Major, but I don't know his history, so if he is autistic he's obviously a very high functioning one if it's true. And if it is, why hadn't he been red flagged? It's not like autism can be cured....

 

[OldPsychDoc]

More to mull over...

 

[Jollygooddoc]

Do you have any experience with forensic psychiatry? Ever seen a violent person with paranoid schizophrenia...let alone a person with a multiple murder conviction? Paranoid schizophrenia is a subtype of schizophrenia that is associated with a high level of function and VIOLENCE. His negative symptoms of alogia, asociality, affective flattening, along with positive Sx of obvious religious and persecutory delusions makes this boy have a poor prognosis especially in the context of absent psychiatric care.

Your saying his life being tragic has roughly zero to do with MI is uneducated at best.

Thumbs up! I am a GP with special interest in psychiatry (had 6 months rotation in Psych on top of my GP training). When I watched the video, I immediately thought that the guy's behaviour fitted well with the diagnosis of paranoid schizophrenia. The diagnosis also fits well with the history. I am just surprised they let the guy go after the initial assessment. I have read he was ordered to undergo outpatient treatment, but was it actually enforced? Does not seem likely. If it was, it clearly was not working, so where was the followup?

 

[OldPsychDoc]

...I am just surprised they let the guy go after the initial assessment. I have read he was ordered to undergo outpatient treatment, but was it actually enforced? Does not seem likely. If it was, it clearly was not working, so where was the followup?

I know that you're not practicing in the US yet, but this seriously doesn't amaze me. Patients get turned back into the community every day in our cities with inadequate follow-up, or manage to evade the follow-up that they really don't want or think they need. I think the story of his 2005 "assessment" could be repeated a thousand times a day in every state in the US. There are not enough psychiatrists, psychologists, social workers, or <insert practitioner here> anywhere in the US to ensure that these folks don't "slip through the cracks". Multiply by the factors of 1) a kid 2) with immigrant parents 3) away from home with 4) completely absent social skills--and 5) readily available weapons in a 6) culture of violence. The surprising thing is really that this happens so rarely!

 

[Solideliquid]

Thumbs up! I am a GP with special interest in psychiatry (had 6 months rotation in Psych on top of my GP training). When I watched the video, I immediately thought that the guy's behaviour fitted well with the diagnosis of paranoid schizophrenia. The diagnosis also fits well with the history. I am just surprised they let the guy go after the initial assessment. I have read he was ordered to undergo outpatient treatment, but was it actually enforced? Does not seem likely. If it was, it clearly was not working, so where was the followup?

Why do you say that? I agree with Villin, if he did have schizophrenia he might likely have the Undifferentiated (or Disorganized?) sub-type.

Some of the signs that point away from paranoid type: His affect was at times flat, he had loose associations or disorganized thinking patterns, disorganized behavior.

My attendings and I constantly have this discussion. The paranoid in chronic paranoid schizophrenia doesn't mean the person is experiencing the symptoms people experience who have paranoid personality disorder. They can be paranoid as a part of DELUSIONS they are experiencing. It is not, however the same as being ever suspicious of others, constantly misinterpreting what others are doing, etc. Sazi any thoughts? OPD?

 

[OldPsychDoc]

Why do you say that? I agree with Villin, if he did have schizophrenia he might likely have the Undifferentiated (or Disorganized?) sub-type.

Some of the signs that point away from paranoid type: His affect was at times flat, he had loose associations or disorganized thinking patterns, disorganized behavior.

My attendings and I constantly have this discussion. The paranoid in chronic paranoid schizophrenia doesn't mean the person is experiencing the symptoms people experience who have paranoid personality disorder. They can be paranoid as a part of DELUSIONS they are experiencing. It is not, however the same as being ever suspicious of others, constantly misinterpreting what others are doing, etc. Sazi any thoughts? OPD?

I'm a lumper, not a splitter. DSM games are fun to play in academia, but in the real world all that matters is Crazy vs. Not Crazy and Depressed vs. Manic.

 

[Jollygooddoc]

I'm a lumper, not a splitter. DSM games are fun to play in academia, but in the real world all that matters is Crazy vs. Not Crazy and Depressed vs. Manic.

I have to agree with this. I am sorry I am not as familiar with DSM as you guys are (ICD-10 is used in Europe). However, the point is that the guy was paranoid, and likely schizophrenic. You may argue that he might have had paranoid PD and schizophrenia, I take your point (though as far as I know - and I am not a psychiatrist - loose associations can be present in any subtype of schizophrenia, not just in disorganised type). I would not say he was very disorganised in general, though, as it appears that he had shown a fair degree of organisation in his planning of the massacre. I have seen some patients with hebephrenia, and whilst they are capable of violence, they tend to do it "on a whim", rather than as a part of a carefully pre-meditated act. At the end of the day, though, all it matters is that the guy needed antipsychotics (+/- psychotherapy), whether you call him paranoid schizophrenic or hebephrenic with the background paranoid PD. Without having more facts, it is hard to determine what it was - even if out of purely academic interest.

 

[Jollygooddoc]

Why do you say that? I agree with Villin, if he did have schizophrenia he might likely have the Undifferentiated (or Disorganized?) sub-type.

Some of the signs that point away from paranoid type: His affect was at times flat, he had loose associations or disorganized thinking patterns, disorganized behavior.

BTW, Villin also said it is likely that it was paranoid schizophrenia. And flat affect may be present in paranoid schizophrenia, right?

 

[Jollygooddoc]

I know that you're not practicing in the US yet, but this seriously doesn't amaze me. Patients get turned back into the community every day in our cities with inadequate follow-up, or manage to evade the follow-up that they really don't want or think they need. I think the story of his 2005 "assessment" could be repeated a thousand times a day in every state in the US. There are not enough psychiatrists, psychologists, social workers, or <insert practitioner here> anywhere in the US to ensure that these folks don't "slip through the cracks". Multiply by the factors of 1) a kid 2) with immigrant parents 3) away from home with 4) completely absent social skills--and 5) readily available weapons in a 6) culture of violence. The surprising thing is really that this happens so rarely!

Sorry about my ignorance. I guess, this bodes well for job security as a psychiatrist (provided one of your patients does not go off like this!). It is really sad, though, that one of the best (and richest) medical systems in the world can allow this to happen. Is this related to insurance pressures? My SO tells me that in the US you are basically discharged by psychiatrist once your insurance company thinks you have had enough mental health care. But, my SO is NOT a medic, much less a psychiatrist, so I have no way of knowing.

 

[yourmomma]

Do you have any experience with forensic psychiatry? Ever seen a violent person with paranoid schizophrenia...let alone a person with a multiple murder conviction? Paranoid schizophrenia is a subtype of schizophrenia that is associated with a high level of function and VIOLENCE. His negative symptoms of alogia, asociality, affective flattening, along with positive Sx of obvious religious and persecutory delusions makes this boy have a poor prognosis especially in the context of absent psychiatric care.

Your saying his life being tragic has roughly zero to do with MI is uneducated at best. For example, ever hear theories on why people with antisocial personality disorder have an associated physical finding of bradycardia? i'll leave it up to you to explore that theory.

Anyway, i've seen some psychiatrists finally being interviewed on the media explaining their thoughts on the mentally ill killer. Mental illness is a real entity that needs to be addressed especially since it comprises 4 out of the top 10 illnesses with the highest global medical burden. Tell me this...how does one voluntarily go through life not saying much of anything EVEN as a child and then ramble on for 1800 words during his psychotic manifesto?

Have a great weekend!

actually forensic psychiatry is the only type of psychiatry i have any extensive (beyond rotations and reading) experience with, as my dad is a forensic psychiatrist... and i'll be clear up front - i'm not including antisocial personality disorder as a mental illness that one suffers from.

i'm not arguing whether mental illness is real or not real. clearly, it is real. but that doesn't mean that everyone who goes around killing people has it. and, i think we do a disservice to the mentally ill when we invoke "sick" every time some guy behaves as a criminal. dsm be damned, the two are not synonymous.

maybe you're right, maybe he went psychotic due to poor mental health treatment for schizophrenia... after all, you ask, how does a guy go from saying nothing his whole life to giving an 1800 word manifesto?

your explanation is one, though i don't think you can reliably count his asocial behavior (or the other negative sx's you mentioned, for that matter) as a negative sx of schizophrenia when he's presumably been asocial and blunted his whole life - unless you believe his onset was age 2 or whatever. with respect to his obvious delusions - maybe i didn't listen to the tape closely enough, but i don't remember thinking they were all that obvious: what specific delusion(s) did you gather?

my thoughts, based on the limited information available, are that he just decided that he wanted to be somebody else, someone cooler, more powerful, someone who is everything he was not. so this little character he played gave him a nice outlet to achieve his goal. this was about who he was, not what he had.

Your saying his life being tragic has roughly zero to do with MI is uneducated at best. this statement made me laugh a little. i think i'm good on the nature of mi, but i would love your thoughts on the nature of tragedy. that would truly make my weekend great.

 

[whopper]

When I watched the video, I immediately thought that the guy's behaviour fitted well with the diagnosis of paranoid schizophrenia. The diagnosis also fits well with the history.

Too early to say IMHO.

While SCPT should clearly be on the radar, in addition to delusional DO, paranoid personality DO, bipolar-I & schizoaffective DO...

Let me give you a counter argument.

The Columbine killers didn't seem to be suffering from SCPT. Too young, didn't fit the profile. The VT killer did have similarites to the Columbine killers.

Let me give you another possible explanation: autistic kid who is from another culture, who took a long time to learn to understand English during critical formative years, who was picked on everyday and couldn't effectively communicate his anger, need for kinship and loneliness just one day blows up.

And to further argue against schizophrenia--
-he was supposedly able to function in an academics
-was able to function on his own in a school setting
-no reported hx yet of schizophrenia from the family
-planned the killings out in an organized manner with supposed planning on the order of weeks before it happened
(Although yes SCPT can have higher level of functioning than other types).

That doesn't fit any of the above dx. It could be a case of neurosis pushed to the extreme & becoming something like psychosis.

This is not typical DSM, this is beyond that, in a manner where this type of thing is not understood by early level psyche residents. These are the types of cases that are rare but do happen & you do tend to notice them much better your 3rd & 4th years.

Anyways--this is just a theory--and I do have 1 pt who fits this description although she didn't get guns and kill people, but did attack people.

Bottom line, and this is following the APA's guidelines, we're not as doctors & psychiatrists supposed to broadcast our diagnosis on someone as official unless we've actually reviewed them in a professional manner-e.g. personal interview, H&P, labwork etc.

Unless that's done, any statement needs to have a strong disclaimer that it is only speculative at best--which I am doing. Even when doing so, this has to be done carefully. Since we are doctors, any statement we make has some legitimacy tacked onto it by the public-whether that legitimacy is actually deserved or not. (Kinda like when celebirties talk about a topic--sometimes they don't know what they're talking about--e.g. Tom Cruise).

Too bad the doctors who were given lots of airtime on the news in the Schiavo case to keep her alive weren't reprimanded. For or against the order to remove her feeding tube, several of the docs that argued to keep her alive claimed she was in a state where she could've recovered (later proven not to be true) and had not followed the guidelines I mentioned.

Bottom line is our debate here is speculative at best.

 

[Solideliquid]

BTW, Villin also said it is likely that it was paranoid schizophrenia. And flat affect may be present in paranoid schizophrenia, right?

Diagnostic criteria for 295.30 (Schizophrenia) Paranoid Type
(cautionary statement)
A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.