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By Donald W. Black

For many years I have pondered the mental state and motivations of mass shooters. The tragic events in Newtown, CT this past week have brought this to the fore. Mass shootings have become everyday occurrences in the United States, and for that reason tend not to attract much attention unless the circumstances are especially heinous, such as this instance in which the victims were young children. We are all left wondering what can be done. While the attention span of the general public and the media is usually a matter of nanoseconds, this mass shooting seems different, and I hope will lead to positive policy changes. This tragedy presents an opportunity for our leaders to step up to the plate and lead and, one hopes, implement rational gun control legislation most of us agree is necessary.

But back to the shooters. As a psychiatrist with an intense interest in bad behavior, I expect that discussions will center on mental health issues which many believe motivate the shooters. I am intensely interested in these “issues” because, to me, the main issue that keeps coming up is that of psychiatric diagnosis. Everyone seems interested in the possibility of a psychiatric diagnosis, because it suggests that we might “understand” the shooter, and this may lead to better identification of future shooters, and both improved treatment and prevention.

But will the presence of a psychiatric diagnosis improve our understanding? Probably not, because — at least in the cases we know about — the apparent psychiatric diagnosis runs the gamut. Some shooters appear to have schizophrenia, others a depressive disorder, and still others a personality disorder, as has been alleged in the case of Adam Lanza. While we seem able to understand that a “crazy” person out of touch with reality might carry out an otherwise senseless act, the thought that someone who is not psychotic carrying out such an act is very unsettling. How could a person who is not psychotic behave this way? For example, depressed persons are by and large not psychotic, yet some will — in the context of being hopeless and suicidal — want to take others with them: spouses, children, etc. More typically, while planning to harm themselves, most depressed persons have no desire to hurt anyone else.

What about the non-psychotic people with a personality disorder? The Diagnostic and Statistical Manual of Mental Disorders — a compendium of psychiatry’s officially recognized disorders (about to come out in its 5th edition) — lists ten personality disorders; the most relevant to our discussion is antisocial personality disorder. This disorder is quite common (up to 4.5% of the population) and causes all manner of problems because the antisocial person always seems to be in trouble with the law, their spouses and families, or their employers.

The term antisocial is almost always misunderstood and is often construed to mean ”shy” or “inhibited,” yet in a psychiatric sense the term suggests rebellion against society. My profession has done a poor job in educating the general public about the disorder and for that reason it remains under the radar screen. (An older term that seems more entrenched is sociopathy.) In the DSM, the diagnosis rests on the person having three or more of seven symptoms (such as deceitfulness, impulsivity, irritability and aggressiveness, etc). Perhaps the most important is “lack of remorse,” which occurs in about half of those diagnosed antisocial. This is what allows the antisocial person to hurt, to mistreat, or even to kill others. These are the “psychopaths” we read about and fear. (Psychopathy is at the extreme end of the antisocial spectrum of behavior.) Few antisocials are killers, but many of today’s mass shooters would fit the description of antisocial personality disorder. I don’t know if Adam Lanza would, but as we peel back the layers of his personal history, we might find that he does.

We don’t know what causes antisocial personality disorder, but like many disorders it probably results from a combination of genetic and environmental factors. I have argued for many years that the federal government needs to direct more funds to investigating its causes and developing effective treatments. Despite its high prevalence and the fact that it contributes to so much of society’s ills, the government has shown little interest in funding research on the disorder. The National Institutes of Health RePORTER website lists only two projects in which the term “antisocial” appears in the title and only five in which the terms “psychopathy” or “psychopathy” are used. Considering that NIH funds literally thousands of projects, this can only be considered hopelessly inadequate. Overcoming this resistance to research on antisocial personality disorder and related conditions must be a priority.

We need wide-ranging projects to explore the origins of antisocial behavior and search for methods to change its course. Geneticists should investigate the mechanisms underlying antisocial behavior, locating genes that might predispose individuals to antisocial behavior and determining how these genes function. Neuroscientists should pinpoint brain regions or networks linked to antisocial behavior and identify biochemical and physiological pathways that influence its expression. A range of treatments — both drugs and therapy — need to be developed, tested, and refined.

Will these steps help us understand the conundrum of the mass shooter? Will they allow us to treat antisocial persons and prevent youth with antisocial tendencies from developing a full-blown disorder? We can certainly hope.

Donald W. Black, MD is a professor of psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. He is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated (Oxford University Press, 2013).

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By J. Reid Meloy, Ph.D.

As the debate concerning public and social policy surrounding gun control intensifies, I would like to offer some comments on the identification of individuals who concern us as potential perpetrators of planned killing(s). These thoughts are from the trenches of threat assessment, and don’t address or offer opinions concerning the larger policy issues we face as a country regarding firearms and public mental health care — one of which is emotionally charged and the other sorely neglected.

The usual demographic characteristics such as a young male, loner, psychiatrically impaired, bullied, and angry don’t work as markers of risk, simply because there are hundreds of thousands of individuals in the USA, and the world, who match these demographics and pose no risk at all. The disturbing fact is that targeted violent events, such as the mass murder in Newtown, cannot be predicted because they are too rare. If we attempt to do this, we err on the side of labeling thousands of individuals as potential perpetrators when they are not a risk at all. So where do we turn?

For the past several years we have been working on identifying warning behaviors (acute and dynamic patterns of risk), which may signal an impending act of targeted violence, including mass murder. These patterns create concern in observers, and warrant a reasonable response to mitigate such risk, whether that involves increased community and educational attention, mental health intervention, or law enforcement interdiction. Anyone can evidence these warning behaviors:

1. Pathway warning behavior: any behavior that is part of research, planning, preparation, or implementation of an attack.
2. Fixation warning behavior: any behavior that indicates an increasingly pathological preoccupation with a person or a cause. There is a noticeable increase in perseveration; strident opinion; negative statements about the target(s); increasing anxiety and/or fear in the target; and an angry emotional undertone. It is accompanied by social or occupational deterioration.
3. Identification warning behavior: any behavior that indicates a psychological desire to be a “pseudocommando” or have a “warrior mentality”, closely associate with weapons or other military paraphernalia, identify with previous attackers or assassins, or identify oneself as an agent to advance a particular cause or belief system.
4. Novel aggression warning behavior: an act of violence which appears unrelated to any pathway warning behavior which is committed for the first time, often to test the ability of the individual to actually do a violent act.
5. Energy burst warning behavior: an increase in the frequency or variety of any noted activities related to the target, even if the activities themselves are relatively innocuous, often in the hours or days before the attack.
6. Leakage warning behavior: the communication to a third party of an intent to do harm to a target through an attack.
7. Last resort warning behavior: increasing desperation or distress through declaration in word of deed; there is no other choice but violence, and the consequences are justified.
8. Directly communicated threat warning behavior: the communication of a direct threat to the target or law enforcement beforehand.

If we observe these warning behaviors in others, we should be concerned. If we see something, we should say something. We don’t know if these warning behaviors predict targeted violence, yet these accelerating patterns have been found in a number of small samples of subjects in Germany and the US that have committed school shootings, mass murders, attacks and assassinations of public figures, and acts of terrorism. We are getting some tantalizing results: in comparing a small sample of school shooters and school threateners in Germany, our research group (with Dr. Jens Hoffmann) found that the school shooters were much more likely to exhibit pathway, fixation, identification, novel aggression, and last resort warning behaviors when compared to the school threateners who had no intention to attack. Although the samples were small, the effect sizes were large in a statistical sense.

The paradox in all this work — targeted violence threat assessment — is that we will never know which of the individuals of concern would have carried out an act of violence if there had been no intervention.

J. Reid Meloy, Ph.D. is Clinical Professor of Psychiatry at the University of California, San Diego, and President of Forensis, Inc., a nonprofit dedicated to forensic psychiatric and psychological research. He co-edited Stalking, Threatening, and Attacking Public Figures (OUP, 2008) with Lorraine Sheridan and Jens Hoffmann, and is currently co-editing another volume entitled International Handbook of Threat Assessment, which is scheduled to publish in 2013. Learn about his latest news by following Forensis on Twitter at @ForensisInc. The scientific basis of this blog article is available in Behavioral Sciences and the Law, 30:256-279, 2012.

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