Inside the Mind of the Shooter, Mental Illness, Murder,

Well it is over a week since the Tuscon tragedy. I like you have watched all the events of the week unfold. The political manuevering over the week; the age old discussions and debates on mental illness are predicatable. I know this is an Alzhiemer's blog. My mother died from Alzheimer's disease 24 years ago. I took care of her, I wrote a book about it. I became a psychiatrist. I treat mental illness.
Lots of people want to know if Alzheimers is a mental illness. They want to know becouse there is much stigma associated with mental illness. People want to know what delusions are: so they come to this blog.
I get frustrated with  the lack of information on mental health and insanity and dangerousness that has been presented in the media this past week following the Arizona tragedy.
I have treated tens of thousands of patients with mental illness over the last 19 years.for various reaons  people dislike psychiatrists and are dissuaded from even begining to understand the plight of the mentlly ill in society.  People are afraid of those with metal illness. There is just so much stigma associated with it.
I have certainly bloggged about this phenomenon before. The stigma is even perpetuated by the propriatary, dismissive attitude toward mental health treatment by the medical community.
There are many initiatives by the goverment and insurance companies and administrative physicians and psychologist types (those that set policies, go to meetings, are 'indsipensible' and DON'T take care of patients all day) to basically "pigeon-hole" everything ie. all mental illness into "DEPRESSION".
It is leading to problems yet it is so politically correct becouse it looks like we are doing so much to improve mental health care delivery. It leads to problems, misdiagnosis, and improper treatment.

I believe we will hear more about this is in about a decade or so when the medical community at large and the policy-makers figure it out and  start to notice that not everything fits easily into the generic catagory of depression.  But you heard it here first. I often see patients that have been so mismanaged by a primary physician, it makes my job much more difficult. Yes it is true the easy cases that have been managed well by primary care, never have any need to come and see me, the specialist. Yet through no fault of their own we are also putting more pressure than ever on primary care do diagnose and treat mental illness.
I am pretty politically incorrect in saying this because sometimes political supercedes clincal, and most people in adminstrative roles don't like to listen to my clincal concerns, or they 'know better'. At any rate I keep doing my best in properly diagnosising and treating patient and taking care of people., in my speicalty.

Now as far as these insanity and murder issues. Insanity is a legal term. It does not mean much from a clinical perspective.   Mental competancy, capacity etc- all legal terms. Manipulated by attorneys, used and misused to sway juries one way or another.  Interpreted and misnterpreted by judges, lawyers and human beings serving on a jury. Human beings are emotional  and feeling people, and every "good" lawyer knows that. There is really no such things as objective facts that are not processed by a human being with emotions, but that is courtroom stuff, see lawyer blogs for that.
Clincally speaking here are the relevent details,
A good psychiatrist in evaluating a patient and arriving at a differential diagnosis  first must figure out if a person is psychotic or not. Psychotic means out of the realm of reality or "reality testing".  Psychotic is not hard to decipher for any reasonable, astute clinician. It manifests with some certain specific basic types of signs and symptoms, some basic signs are hallucinaitons and delusions. 
Hearing voices is a basic type of psychotic symptom, Once again for an astute clinician this is pretty basic and not difficult to diagnose.
I suppose the term astute is relative. I have evaluated and treated tens of thousands of patients in psychiatry, including lots of murderers, rapists and various other criminals.  So maybe I think it should not be too hard. The scary truth of the matter is, that many mental health practicioners  don't know there butt from a hole in the ground when it comes to evaluating if someone is psychotic or not. Many family doctors perhaps even a majority, are also not competent in evaluating if somone is psychotic or not.
So with that said becouse I have many years of experience in doing this, it makes some people angry resentful and hostile. "How can you tell if somone is psychotic from talking to them for a few minutes" I can't say much to that except, you don't call a plummer when there is a leak under your car, you call a mechanic. Part of the reason it makes poeple resentful that I have expertise in this area, is those people tend to have a horrible prejudice about mental illness. They consider diagosing somone with mental illness as some sort of value judgement. Perhaps a judgement on character, and since I am diangostician, I am the "judger" in their mind. It is more about the stigma and bias and fear those individuals carry about mental illness. As you might imagine it does nto motivate people to go into or stay in psychiatry.

Anyways here is a BASIC concept with tremendous relevence to the current geopolitical climate in the United States.. When it come to delusions (fixed beliefs not grounded in reality testing). There are certain basic areas to always ask about. for example Pre-occupations with Religious, somatic, and grandiosity and paranoia.
There are certain areas of paranoia to always inquire about when performing a psychiatric assessment.
These certian sub-areas of content in paranoia for example include such things as aliens, mind control, satanic, religious and government.   
This is something I learned all about over 20 years ago in my psychiatric training, It is something assessed in any competent psychiatric evaluation. It is something I have dealt with in patients and continue to deal with on a daily basis almost every day of my profesisonal life.
The concept of  paranoia about the government has always been a common theme in psychotic paranoia. not everyone with psychosis has this issue, but it is still common enough to always need to be assessed. It has absolutely nothing to do with the tea party, or Obama, or Bush, or Clinton, or Republicans or Democrats or Palin, or Beck, or Medow or Fox or CNBC. It has absolutely nothing to do with economic cycles.
The specific delusion may vary slightly with popular culture for example in the 1960's there may have been more psychotic people worried about martians or aliens from Mars when that science fiction was popular, in the 1980's there may have been more paranoid people worried about communists and Soviets doing bad things like planting microchips in ones brain while they slept. The point is psychotic paranoia is an illness and a common area of content involves goverment, mind ocntrol etc. Not new, not interesting per say, just a common area of psychitry, like a plumber fixing a leak, a computer tech fixing a slow hard drive.
Now when we talk of schizophrenia- a psyhcoitc disorder, that affects about 2% of the population WORLD-WIDE. That number is fairly consistent across cultures. In the USA that is 6 million people give or take a few.  Did Glenn Beck or OBama increase the number of schizophremic people in the United States? Absolutely not. It does not work that way.
Most people with schizophrenia are not dangerous or viloent. untreated paranoid schizophrenia can lead to more dangerousness. Wow!  How can a person like the Tuscon shooter slip through the cracks?
If this person who killed those innnoecnt people and wounded others, had had a psychiatrist, most likely that psychitrist would have been blamed. Thats how we view things in the USA. But he apparently did not have treatment, so we blame the inadequate system.

It is flawed and inadequate, not question there.

The fact of the matter is, if you take that 6 million people, many are not treated, no one knows exactly how many, but say a million. Those untreated individuals are out and about living with parents or homeless, or in college dorms or sitting around with a bunch or dis-enfranchised 20 year olds smoking pot doing whatever,being paranoid, threatening, fantasizing, obsessing about conspiracy, goverment control, mind control, or whatever delusional material you want. they cause disturbance sometimes, post things on facebook and internet, and usually fly under the radar and don't act on their threats or fantasies. It happens all the time eveyr day and all over the country. No one can predict with consistent accuracy which one sending off signals and warning signs is going to act. There are a lot of people sending off warning signals as we speak, and sadly they are nto getting help or treatment. The only thing that predicts future behavior is past acts.It is not new to this political climate and has been happening for centuries.
Schizoprehnia starts when you are young. It is a chronic incurrable disease of young people typically with onset around 17-25 years of age.There is not a cure. It is treatable but not curable.
So what do we do?
The currect system is flawed. Yes lawyers and the ACLU and society in general wants to protect peoples civil rights. Yes the mental health system has committed abuses namely by neglect, in state hospital about 60-90 years ago. The pendulum has swung the other way. We have the media, angry reporters so mis-informed and condemming doctors, drug companies and the like. We have family doctors poorly trained in mental health and psychitatry or not trianed at all, trying to categorize and treat mental illness, and sometimes making it worse. We have very few young physicians going into psychiatry. In my community and in many communities we have untrained psychologists trying to pracitce psychopharmacology and advise family doctors how to practice psychiatry. The situaiton is unbelievable. We have psychologists and psychotherapists and the media and even certain members in the medical commiunity at  large cristicizing psychiatry, and of course that coupled with very low pay compared to every other medical speicalty except pediatrics- For all the young doctors coming out of medical school. almost NO ONE wants to train in and practice psychiatry.

So what was going on in the mind of the shooter? Did he have schizphrenia? Most likely from the bits and pieces presented by the media. Paranoia is a projection of one's aggressive drives. Every single person has drives: eg aggressive drives, sex drive, hunger drive,  but we are higher functioning psychological beings so we learn to surpress and repress and sublimate aggresive drives, we become social and empathic and compassionate beings hopefully. It takes some reaonsable genetics and environmental nurturing at an early age. 
A person with schizophrenia may hear voices, they may become so fixated on their delusional beliefs that can't think about anything else. It becomes all encompassing. They become paranoid: that is thinking others are out to hurt them or kill then because it is too psyhcologically overwhelming and forbidden and destructive to deal with aggressive drives.  The process is highly unconscious. Sort of like dreaming.
A Psychological projection is what paranoia is.  A primitive drive, a desire to hurt someone, projected onto somone else. "They want to hurt me"  nothing new, a psychological understanding that has been around for a hundred years, that many therapists in this day and age do not learn or have a concept of,
generally viewed as a bunch of psychobabble BS. Except if you understand the psychological defense it makes a lot of sense.
In this day and age there is much more biological theory on schizphrenia than psychological theory. Dopamine,  has been classically linked to schizophrenia, people with schizophrenia have structural changes in their brain that others do not, for example they have larger cerebral ventricles.
Twins raised apart in different environments from birth have a higher incidence of schizophrenia  between them. That is if one twin has schizophrenia, the liklihood of the other having it, despite different environments is higher than average probability- Leading to the theory that there is some genetic component to schizophrenia. Like Alzheimer's though, the exacct genetic links are not  well understood.v Other neurotransmitter like glutamte and glycine and many others have been and are being studied,
Another way of thinking about schizophrenia, is that the mind of a schiophrenic is  almost like someone without schizophrenia having a bizzare dream. There is no time relationship in dreams they are often weird and bizzare, and then you wake up.
Some data shows that people with schizophrenia when relaying the content of their dreams have very NORMAL dreams. that su what would be considered normal everyday life for somone that does not have schizophrenia. Dreaming is a psyhoclogical primary process. Another possible way to think about or understand schizophrenia is being  in a bizzare dream where you can't wake up.   Only that person with schizophrenia is wide awake and conscious.

Well I could talk about this stuff all day. I wish there was less stigma, I wish the media could do more accurate reporting. I wish there was not always a political platform somewhere. This is my job, it is what I do. I often deal with dangerous patients and sometimes my life is life is at risk.
Mental illness and the inadequacy of the system only seems to get addressed ion the collecitve consciousness of Americans over situations like Tuscon. I wish the dialogue would continue, I wish the politcs were taklen out. Inevitably however, the politics will continue and the mental health dialogue will slowly die out over the weeks.