JAMA Psychiatry: Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning

[NNadir]

I sort of stumbled upon this article in my JAMA newsfeed: Knoll J 4th, Dietz P. Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning. JAMA Psychiatry. 2023 Feb 1;80(2):186-188

The spate of mass killings, almost all related to the ready availability of guns is disturbing, and I'm personally trying not to think so much about the perpetrators, thinking they get off on the fame, but rather the victims.

Nevertheless, I wonder how it is that people come to doing this.

Without much comment, some excerpts from the article:

When psychiatric leaders state that mass violence, mass murder, or mass shootings are not caused by mental illness, the public understandably reacts with dismissive incredulity. Does not basic logic dictate that mental illness is a necessary precondition for being able to carry out such an act? The answer is complex, and it is possible that psychiatry has done a poor job of clarifying what must seem to the public like a specious conclusion. The confusion may partially stem from inconsistencies in the definitions used for mass violence as well as a failure to clarify what constitutes mental illness.

With respect to definitions, researchers, journalists, and other commentators have inconsistent quantitative and qualitative thresholds for declaring an event mass violence, mass murder, or a mass shooting. These basic definitional issues determine whether such events appear more common (by including nonfatal injuries and fewer people who are killed) or less common (by only including fatal injuries and more people who are killed). There are also inconsistencies in whether writers are excluding events within families, gang-related events, events in certain settings, or events in which certain weapons were used. Such inconsistencies make it difficult to compare data among studies of similar, but not identical, events and may be strongly associated with the number of events encompassed, the characteristics and motives discerned for the violent actors, and the opportunity to detect root causes of the behavior.

To our knowledge, no study has ever found that most of those engaging in mass violence of any kind have a psychotic mental illness or are taking psychotropic medications,1,2 and this is what psychiatrists usually have in mind when they dismiss the assertion that mental illness or psychotropic medications are the primary cause of mass violence. For example, 2 publications based on a US Federal Bureau of Investigation (FBI) study of active shooters from 2000 to 20133,4 found that only 25% of perpetrators had ever received a diagnosis of mental illness and concluded, “[A]bsent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.” Likewise, Hall et al1 reviewed available information regarding individuals involved in educational institution shootings per the FBI publications on active shooters from 2000 to 2017 and found that most school shooters were not previously treated with psychotropic medications and concluded that “by either the primary measure of documented psychotropic treatment at any time prior to the event, or the secondary measure of a successful NGRI (not guilty by reason of insanity) defense, it does not appear that most school shooters had been prescribed psychotropic medications prior to the shooting or were negatively impacted by the medications.”

Psychiatrists, and particularly forensic psychiatrists, understand that acts of violence are often committed for reasons other than mental illness. During their training, forensic psychiatrists quickly learn what a mistake it is to assume a crime was associated with a mental illness simply because it was horrific, deviant, or bizarre. When a serial murderer is apprehended after sexually assaulting and killing a dozen people and keeping body parts in their home, it is impossible to argue that this is normal or rational behavior. Is their pattern of luring people into their home, binding them, torturing them, and retaining their body parts prima facie evidence of a serious mental illness? It would almost always be incorrect to assume so, but the pull is strong. It is more comforting to believe that a disease of the mind overtook them and caused these unspeakable acts. There is nothing reassuring about the notion that the individuals’ lives were less important to them than their own sexual gratification. However, to comfort themselves, the public wants to believe that outside forces cause unspeakable acts; hence, the legends of vampires and werewolves, the fascination with transformations of Dr Jekyll into Mr Hyde and Dr Bruce Banner into the Hulk, and the impulse to assume that mass murder arises from mental illness...

...researchers have begun to investigate a higher-order classification system based on a spectrum, or dimensional approach, which is now receiving robust attention.6 There has been substantial research around dimensionality and mental illness, leading some to assert it may be superior for future scientific study.7,8 Dimensional approaches vary, but one approach aggregates psychiatric symptoms into 3 domains of psychopathology: (1) internalizing, (2) externalizing, and (3) psychotic experience. This tripartite dimensional approach has practical clinical use and research support...

... This approach may also help clarify misconceptions about the rate of psychosis in mass violence perpetrators, as well as which parts of the spectrum of mental functioning are most associated with perpetrators. For example, a testable hypothesis might be that most mass violence offenders are externalizing, given their personality structure, absence of clear psychotic symptoms, and inability to process intrapsychic conflicts in a prosocial manner. Several may have co-occurring externalizing/internalizing problems, while some may have psychosis. There is now a large body of research suggesting that internalizing and externalizing problems often co-occur.9 This externalizing spectrum hypothesis seems reasonable, given that there is now much evidence of an association between emotion dysregulation/impulsiveness, psychopathy, narcissism, and antisocial spectrum pathology and increased risk of violence.10 Approximately half (45.6%) of mass school shootings ended with the perpetrator's suicide...11

...Personality and personality disorder are concepts referring to the characteristic patterns of thoughts, feelings, and behaviors of an individual that are consistent over time and contexts. The reason to be somewhat optimistic about studying mass violence in terms of the externalizing and internalizing personality dimensions is that such psychopathology might be observed and mitigated by early childhood and other treatment interventions. Personality can be partially viewed as an adaptation strategy that is associated in some degree with the environment and social changes. Can early interventions be made in children’s psychosocial environments that will produce more prosocial outcomes? Research already suggests that personality traits associated with empathy and attunement to others’ emotions are associated with an aversion to harming others and a tendency to benefit others.13 In contrast, personality styles associated with decreased empathy and emotional callousness are more likely to be associated with strained interpersonal relationships and various forms of psychopathology...

... In sum, psychiatry has struggled to clarify the type of mental turmoil that is associated with mass violence for the following reasons: (1) the behavior of most perpetrators does not appear to be associated with psychotic mental illness; (2) psychiatrists typically wish to protect vulnerable patient populations who are experiencing serious mental disorders, most of whom are nonviolent, from the stigma attached to mass violence; and (3) most in-depth analyses of mass violence offenders suggest that they function in the externalizing and internalizing personality disorder domains...

I don't know what to say about any of this, and am hardly competent to do so, but it struck me as interesting. I worried about this when my kids were in high school, particularly since there were some "edgy" kids there, and I still worry about it with a son still at a university.

It sucks.