Dr. Grossi's Blog
This blog was stimulated by the confluence of several events at the end of May and beginning of June. I was asked by the parent of a patient about my experience as the expert witness in the 1972 Prosenjit Poddar trial which became the Tarasoff case. The rules derived from that California Supreme Court case still govern the disclosure psychiatrists and other mental health workers must make when a patient is threatening harm to someone in the community. A few days after discussing this case, a young Californian, Roger Elliot, killed six people near Santa Barbara. About two weeks later 60 Minutes had an extended piece on mass murderers. In the past I have avoided high profile topics like this in these blogs; however, I decided to make an exception in this matter because I have had some experience as an expert in certain murder defenses and there are substantial debatable public health and safety issues which need airing.
A cardinal distinction that psychiatrists draw when evaluating any patient or perpetrator is whether the individual is psychotic. This broad term is often defined as "loss of contact with reality", and typically includes hallucinations, delusions, inability to think clearly, drawing incorrect conclusions which cannot be corrected even when clear contradictory information is presented. Some recent examples include James Holmes who thought he was "The Joker" and killed twelve people at a Colorado theater; Anders Breivik thought he was the future ruler of Norway, Europe's Perfect Knight and killed seventy-seven people in Norway; and Seung-Hui Cho who thought he was Jesus Christ and said he vacationed with Vladimir Putin in North Carolina. He killed thirty-two at Virginia Tech. Psychosis can be caused by a psychiatric illness, substances, or medical illness.
About 2.7 to 3 million people in the United States population of approximately 317 million people suffer from severe mental illnesses and about one in seven commit murder. Of this number about 50% are psychotic. The remaining 50% are motivated by anger, jealousy, revenge, or attention secured by being a "copy cat." These numbers exclude war, terrorism, and gang activity.
There are a number of features that distinguish psychotic killers from non-psychotic killers. The psychotic killer usually acts alone, rarely tries to flee from the authorities, and is usually killed at the scene either by suicide or "suicide by cop." They are generally not under the influence of alcohol or drugs, are Caucasian and older than thirty, often unemployed, and usually telegraph their plans verbally, in writing, or on the internet. When looking back at their lives, they often demonstrate a fluctuating level of functioning from superior to impaired. Their actions are not usually impulsive but planned and they often know that they are behaving illegally. The individuals at greatest risk are family, friends, neighbors and mental health workers.
There are about 20 instances of psychotic mass murder in the United States each year. This rate has been stable for the last forty years. This is both a public health and safety problem. The public debate about prevention in the United States is almost exclusively focused on gun control. In my view this is too narrow a focus. I think a comprehensive strategy needs to be considered beyond guns because they are generally available and plentiful. Furthermore they are not always the instrument used in these tragedies. In addition, a significant number of psychotic perpetrators have been in contact with the mental health system but have been ineffectively treated. This shouts out loud and clear to me that the system needs reform. Such reform would perforce require a reappraisal of the balance between individual freedom and involuntary treatment or commitment. Once the public debate has taken place, community leaders should shepherd the changes into law. Follow up for patients discharged from psychiatric units needs study and improvement. Certain treatment modalities, long acting injections for certain patients, need to be discussed and guidelines for their use changed so as to increase medication compliance in very problematic patients. Finally, it strikes me as inappropriate to task the police with evaluating the mental state of individuals in the community. These evaluation when done properly require a working knowledge of psychiatric conditions, physiological responses to legal and illegal substances, and the impact of social circumstances on the individual in question. These evaluations should be performed by well-trained and experienced mental health professionals if the community interest is maximum accuracy and minimum errors.
One week ago a patient was talking to me in the office and disclosed that he was paranoid about a particular upcoming experience. He was using the word as a synonym for anxious, tense, apprehensive. This represents a colloquial slang usage of the word "paranoid." Psychiatrists use the word paranoid to mean suspicious, mistrustful. I will not be addressing a common form found in paranoid schizophrenia, because that would be mixing two confusing diagnoses, i.e., paranoid and schizophrenia. Paranoia is a way of thinking or feeling that is pervasive and whose severity varies from relatively mild to loss of reality as, for example, in delusions. The more severe, the more normal functioning is compromised.
Traits of people who are often paranoid include those who are emotionally constricted, fearful, and suspicious. Others are rigidly arrogant and more aggressively suspicious.The trait or attitude of suspiciousness involves the continual expectation of trickery and if chronic leads to a way of thinking. Rigidity refers to having something on a person's mind which causes that person to look at their experience with certain expectations and search for confirmation of those expectations. If someone tries to dissuade the individual from his original view, that person will become an object of suspicion. So, the paranoid person does not pay attention to new facts, doesn't see apparent meaning, but "looks through" the obvious and sees an aspect that confirms the original view, i.e., examination of the data takes place with prejudice so that there is confirmation of the original thought. Anything that contradicts this is dismissed as mere appearance. The paranoid individual is incapable of any other type of attention. His attention is tense, rigid, actively searching with a biased purpose and intensely concentrating.
Everyone has some expectations to help guide them in their view. We are all influenced by what we see and what we don't expect. Those people that are suggestible are easily influenced by whatever striking fact or view or opinion presents itself. People with strong views impose their anticipation on the facts. Paranoid people seek confirmation of their anticipations and these in turn allow them to disregard apparent contradictory facts. In this way the paranoid's mind becomes an instrument of bias and leads to "brilliantly perceptive mistakes", that is, the perception can be correct but the judgment wrong. They are hypersensitive and hyperalert. Anything out of the ordinary or surprising triggers their suspiciousness and heightens their extreme tension. What would appear to be obvious to most people in a given circumstance is to them mere appearance and disregarded. They need to look beyond. They listen for clues. In this was they loose the tone and color of experience and those features that modify and qualify experience or convey a sense of proportion or scale. They are over represented in fanatics. These are the cognitive mechanisms that lead to a distortion of reality or in the extreme a loss of reality.
Two well known psychiatric researchers, Kendler and Gardner, recently published the results of examining over a thousand twins in the Virginia Twin Registry. These results have shown light on new and added weight to prior findings regarding gender differences in males and females. The most important factors contributing to major depression in women included divorce, lack of social support, marital dissatisfaction, and personality traits of shyness, anger, and anxiety. For men occupational stressors, financial stressors, drug abuse and childhood sexual abuse were most important. In keeping with these findings, men's depressions are defined by inability to achieve goals and lowered self-esteem whereas women's depressions are associated with deficiencies in caring relationships. These are stereotypical findings and may be related to the population studied which is not age representative for the country nor is it representative of the urban/rural mix of the country.
There are other putative gender differences. About ten years ago, another group including Alan Schatzberg of Stanford, published their treatment response findings in many hundreds of depressed men and women. They found that men responded better to imipramine (Tofranil) a tricyclic antidepressant than women did and that women responded better to sertraline (Zoloft) and SSRIs than men. From the point of view of impact on children, there have been several studies in recent years showing that depressed mothers produce a greater risk for depression in their children. There are also several studies demonstrating that children's depression in a family with a depressed mother show marked improvement if the mother's depression remits. These studies underline the need for prompt and effective treatment for depressed individuals in families especially mothers of young children.