Jun 18 2015

Little research on mass murder

Ever since the mass shooting on Fort Hood on 5 Nov 2009, I’ve been interested in the psychology of mass murderers. Being the kind of person I am, I turned to Amazon, searching for books on the subject. I found a lot on serial killers and some on school shooters, but almost nothing on mass murderers. I’m not sure I understand why. It is true that many of these killers are themselves killed before any interviewing or interrogation can be done. Still, I’d think there’d be at least some information, some research into what’s going on with these folks.

Just speculating, it seems to me that the motivations are varied. There seems to be one subset that includes individuals like the killer on trial right now in Colorado who is blatantly psychotic or at least extremely mentally ill. The Virginia Tech shooter seems to have fallen into this category as well.

Then we have the subset of killers who shoot up the work-place. Oddly, I’ve seen little research into what’s going on with these folks.

There has been speculation that Charles Whitman, who shot people from the bell tower at the University of Texas in Austin so many years ago, had some brain tumor. More recently, however, I’ve read that the odds are slim that this tumor had anything to do with his behavior that day.

And now we have the shooter in South Carolina who vocalized a desire to kill African-Americans. So, “it’s a hate crime.” Toss it off with an easy generalization and be done with it. But how does a 21 year old develop such hatred and anger to end up doing what he apparently did? Putting the label on him as “racist” doesn’t really tell us much. As a writer of fiction, if I had a villain who was a mass murderer of some racial group, but didn’t go any further than characterize him as a “racist”, I’d be criticized that my character is made of nothing but cardboard, a caricature. To do that villain justice, I’d need to understand how that hatred developed and I’d need to ground this in some sort of reality about racism (or whatever it is that motivate a mass murderer).

If any of you out there have any insights on mass murderers, please make a comment or contact me. I’d love to hear from you.

May 30 2015

“Crossing Lines”: The role of psychiatrists

Last night I watched the final episode of the tv show “Crossing Lines”. It featured a psychiatrist who had been treating a bad guy in prison for a couple years, supposedly twice a week. Now, I fully understand “poetic license” and I acknowledge that procedures in Europe are likely to be different from those followed in the US. Still and all, it struck me that this psychiatrist was supposed to be doing some sort of therapy with the bad guy. This was, of course, never specified.

I find it unlikely that a psychiatrist, who usually focuses on medication management, would be doing such therapy, whatever it was. Sure, the story needed to have the psychiatrist “fall in love” with the bad guy (or not). Or perhaps she needed to get bored or whatever it was that was supposed to motivate her. If the story needed to have a professional in frequent and protracted contact with the bad guy, why oh why couldn’t the author have specified her profession as a psychologist? It would have changed nothing to the story line but it would have made the story more plausible. She would still have been a “doctor”, carrying the status that involves. A simple change and the story would have made more sense.

BTW, the writers did handle another aspect fairly well. When questioned about the psychiatrist staying in the home of a former patient, the doc makes it clear that the friendship developed a year after termination of the therapeutic relationship. In the US, developing a personal, sexual relationship with a client is a big no-no. Really big no-no. In California, a psychologist is restricted from a sexual relationship following a therapy relationship for two years. Non-sexual relationships are not specifically mentioned. So, why did the writer’s make a big deal about this? I’m not sure but at least they were aware of the potential for an ethical problem here.

I don’t understand why the writers of this show felt that they needed to have the doc be a psychiatrist. There was never an issue about medications. Why not, then, use the profession that would have made some sense?

CROSSING LINES -- Season: 1 -- Pictured: (l-r) Donald Sutherland as Dorn, Richard Flood as Tommy McConnel, William Fichtner as Carl Hickman, Gabriella Pession as Eva Vittoria, Tom Wlaschiha as Sebastian Berger and Marc Lavoine as Louis Bernard -- (Photo by: Dusan Martincek/Tandem)

CROSSING LINES — Season: 1 — Pictured: (l-r) Donald Sutherland as Dorn, Richard Flood as Tommy McConnel, William Fichtner as Carl Hickman, Gabriella Pession as Eva Vittoria, Tom Wlaschiha as Sebastian Berger and Marc Lavoine as Louis Bernard — (Photo by: Dusan Martincek/Tandem)

May 29 2015

Insanity vs mentally ill: the case of James Holmes

Apparently James Holmes has pleaded not guilty by reason of insanity. This week, copies of his notebooks were released which seem to show that he carefully selected his target (the movie theater) and also seemed to be quite aware that what he was doing was wrong. This would argue against a finding of legal insanity. He knew what he was doing and knew it was wrong.

The writings also make it clear that he was (and probably is) very mentally ill. His illness seemed to torment him, from what I’ve heard on the news. This is something I’ve seen in many of my clients over the years. Very often they know something is wrong with them but they don’t know what to do about it. I find it almost heartbreaking that Holmes seems to have studied neuroscience in an attempt to figure out what was wrong with him. I can almost imagine the despair when his studies didn’t provide him with the answers he sought.

From what I’ve gathered in the news, it seems unlikely he will be found insane by the standards in Colorado. That’s not to say that this killer isn’t sick. He most definitely is. I suppose his illness will become important again when we get to sentencing.

As an example of the difference between the legal term “insanity” and the more medical term of “mentally ill” or even “schizophrenic”, this is about as perfect as you can get.

BTW: we are dealing here with a serious mental illness like schizophrenia. We are not talking about a personality disorder or psychopathy. Please, please do not confuse psychopathy with “psychotic” or insane. Personally I do think psychopaths are “sick”, but not like Holmes. Apples and oranges, folks. Apples and oranges.

JamesHolmesColoradoShootingAndyCrossColorado theater shooting suspect James Holmes

May 28 2015

Life Impinges Sometimes: Stress

Sorry I haven’t been around lately. It’s been a difficult month or so and I find it difficult to write about psychology and mental health problems when I’m upset and stressed myself. Guess it gets just a bit too close. I want to provide you all with the best information I can and I don’t want my own issues and difficulties to unduly slant what I write.

So, is there anything I can learn from the past couple months that I can pass on to you, my readers? Any insights that can help you develop realistic characters? I’m not sure. I’m sorting through my thoughts at this point. I can say that prolonged stress can really alter the way a character (and person!) acts and thinks and feels. Even a highly competent character can realistically be expected to have difficulties when trying to cope with prolonged stress.

This reminds my of some old research on stress. I don’t recall the researchers and I probably don’t have the details right, but when dogs were exposed to electric shock in the floors of a cage and they couldn’t predict or control what was happening, eventually they just ended up cowering in a corner. This led to the development of the idea of “Learned Helplessness.” (I know: the ethics of such research are questionable to me too.) For humans, the reaction may show up in a person (character) staying in bed, or spending all the time playing solitaire or some such game. It’s avoidance and at the same time, a giving up.

Cognitively, the thoughts may be something like “Why bother?” Thinking is difficult and feels muddied or like your character’s head is encased in cotton or molasses. It’s hard to see beyond the immediate. Of course, that tends to keep the stress going in many cases.

The stress your character is going through doesn’t have to be life threatening, like captivity and torture. I would think (I don’t know, haven’t done much reading in this area) that learned helplessness might just develop in such situations also. I would recommend if your character is in such dire straits that you do a bit of research on the effects of torture and prolonged captivity. Amnesty International might be a place to start.

So, what sort of things could set this up? Caring for an elderly, demanding parent; living in an abusive relationship; poverty and inability to make ends meet; chronic illness. The list is probably endless.

Mar 31 2015

Personality Disorders

I’m going to continue to talk about the #Germanwings case since someone on CNN has brought up the possibility that Andreas Lubitz had some sort of personality disorder. I’ll talk about the specific personality disorders in later posts.

Personality disorders are long-term, pervasive ways of relating to the world. There are a variety which include Anti-Social, Borderline, Narcissistic, Paranoid, Histrionic, and others. All are different. Note that: all are different. A Histrionic person will seem very different from the person with Paranoid Personality Disorder. Personality disorders are also more difficult to diagnose in many cases. They can underlie the more acute mental illnesses most of us think of when we talk about mental health problems. Or they can stand alone and the person with the personality disorder may never suffer from any other acute mental illness.

Nothing I’ve heard so far leads me to think that Lubitz suffered from a personality disorder. He may have or he may have not. I can’t tell from what’s been in the media. Yes, some people with a personality disorder may kill others. But not all. And not all killers have a personality disorder. To assume a personality disorder just because this individual killed 149 other people is not professional.

Back when I was in graduate school, my class was discussing the issue of insanity. During the break, the professor and a couple of us were sitting at a table talking about crime and mental illness. It was mentioned that anyone who could kill others had to be mentally ill. I mean, it just made sense. We all nodded our heads, but the professor cautioned us. We can’t diagnose by one action and insanity was a legal issue (as I’ve mentioned in a prior post).

Just a quick note: a person with Anti-social Personality Disorder (which includes psychopaths) rarely suffers from depression. The exception being when they get caught. So, in this case, Lubitz’s history of depression and anxiety argue AGAINST him suffering from Anit-Social Personality Disorder. Could he have suffered from a different personality disorder? Of course, but we just don’t have the information at this point. A person with Borderline Personality Disorder or Narcissistic Personality Disorder or Paranoid Personality Disorder could all commit murder, even mass murder.

For writers: if you decide you want your character to have a personality disorder, be sure to show the full picture. If you have a character saying, based on extremely limited information, “He’s got a personality disorder”, please have someone call that character out as an idiot who doesn’t know what he’s talking about.

Mar 30 2015

Antipsychotic Medication and Flying

Okay, folks, let’s talk about antipsychotic meds. Remember, I’m a psychologist and not a psychiatrist. However, many of my clients over the years have taken these medications, so I think I have more than a passing knowledge of them.

Antipsychotic medications are primarily used to treat psychotic disorders. Makes sense, eh? Specifically, these medications help with the hallucinations and delusions experienced during many psychoses. I have sent patients to psychiatrists when it’s clear they’re suffering from a psychotic disorder. There are two basic types: the older “typical” antipsychotics and the newer “atypical” antipsychotics. The typical antipsychotic include Chlorpromazine (Thorazine) and Haloperidol (Haldol). The “atypicals” include:Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel),Ziprasidone (Geodon), Aripiprazole (Abilify), Paliperidone (Invega), and Lurasidone (Latuda).

In recent years (say the past 10 or so), I’ve seen antipsychotics also being used as sleep aids and to help when patients are highly agitated. I’m not sure I really agree with this, particularly because of all the side effects. But I have seen it. BTW, the use of antipsychotics for agitation has been something I’ve seen in hospitals and is usually administered by injection (at least in my experience).

The side effects are numerous and can be very serious. Here’s what the NIMH (National Institute of Mental Health) has to say:

Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

  • Drowsiness
  • Dizziness when changing positions
  • Blurred vision
  • Rapid heartbeat
  • Sensitivity to the sun
  • Skin rashes
  • Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person’s metabolism. This may increase a person’s risk of getting diabetes and high cholesterol.

In addition they note:

Typical antipsychotic medications can cause side effects related to physical movement, such as:

  • Rigidity
  • Persistent muscle spasms
  • Tremors
  • Restlessness.

Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can’t control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.

These other side effects are not as common with the atypicals.

The next question is whether or not a person on any of these medications should be flying. Unequivocally I can say: NO! No matter what the reason for the use of the meds. My opinion. I don’t think a person on antipsychotics should be using heavy machinery either. Should they drive a car? Not at first, not until they know how it’s going to affect them. I can tell you, though, that most of those clients of mine in the past who were on antipsychotics *did* drive. To the best of my knowledge, psychiatrists are not required to contact the Department of Motor Vehicles (DMV) when they prescribe antipsychotics. They probably don’t contact the FAA either if the patient happens to be a pilot. Is this a loophole that should be plugged? I don’t know.

For you writers: consider having a character who is taking Seroquel for sleep (i.e. she’s not psychotic) and struggling with the side effects of that medication. A number of the soldiers I’ve worked with had been prescribed this med for sleep and they had a horrible time showing up on time for formation at zero-dark-thirty. So, now they were getting in trouble for that!

Mar 30 2015

Suicidal Thoughts and Pilots…and the rest of us

flying

CNN tells me this morning that Andreas Lubitz was depressed and suicidal back in 2009, before he got his pilot’s license. It is unclear at the moment if he was experiencing only thoughts or had actually made an attempt. We also don’t know what prompted him to think about suicide. We do know that becoming a pilot was a dream of his, something he was apparently passionate about.

We do not know how he was doing psychologically between 2009/2010 and now, about 5 years later. Depression doesn’t necessarily linger. It is treatable or can even go away on its own in come cases. Suicidal thoughts also come and go. And it’s important to point out that many, many people — I’d actually say most people — have suicidal thoughts at some point in their lives.

In the US, pilots can apply for a waiver if they are suffering from mild to moderate depression and are on certain medications. It is not an automatic grounding in the US any more for a pilot to be depressed. I don’t know what Germany’s standards are. If any of you know, please let me know!

When I’ve dealt with suicidal patients (and a lot of them were at some point or another), I asked about plans and intent. Most had no plan or intent. They’d insist that they’d “never do that” for a variety of reasons and in most cases, I believed them. I’d be more concerned if they had a specific plan. “I’d blow my brains out.” However, if they didn’t have a gun or access to one I’d be less concerned. However, I would be concerned. As a psychologist, my duty is primarily focused on taking care of my patient, so I’d be working hard to convince the patient that hospitalization would be a good move. On a couple occasions, I’ve called the police out for clients who’ve called me and led me to believe they were suicidal. Some got mad at me for doing this, but I was glad they were still around to be mad. Yes, under the law, I can break confidentiality if I think a person is a harm to self (or others). Calling an employer … that’s something I’ve never done and I wonder if, given the confidentiality laws, I’d be allowed to do that. I think if I had a pilot who told me he was suicidal and planned to crash an airliner, I’d call the employer or at least a doc working for the airline and take the hit on my license later.

I suppose that if Lubitz was still in therapy (that’s still unclear to me) and he told the therapist that he was suicidal and planning on crashing an airliner, the therapist would have taken some action to prevent this. More likely, if Lubitz mentioned anything at all about being suicidal at present, he was vague about it. Consider also that this guy loved flying. It was important to him. Very important. Perhaps the most important thing in the world to him. As a therapist, I’d have to consider this. If I take steps to ground him, am I actually increasing the odds that he’ll take his own life? Have I then removed the last thing that mattered to him? It’s a horrible dilemma, one I’m glad I’ve never had to face. (BTW: for you writers. This could make a really interesting short story.)

Mar 29 2015

Generalized Anxiety Disorder

Just heard that the copilot, Andreas Lubitz, on the Germanwings plane that crashed in the Alps suffered from Generalized Anxiety Disorder. But I’m also hearing about some sort of “psychotic episode” in 2010 and had anti-psychotic medications. Let’s talk about each of these issues separately.

First off, just what is “Generalized Anxiety Disorder”. In a nutshell, it means that a person is having anxiety that is triggered by any number of things. If he felt anxiety related to just one thing, say heights, he would have been diagnosed as having a Simple Phobia. The sufferer from GAD feels anxiety and worries about all sorts of things “such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties.[2][3] Individuals often exhibit a variety of physical symptoms, including fatigue, fidgeting, headaches, nausea, numbness in hands and feet, muscle tension, muscle aches, difficulty swallowing, bouts of difficulty breathing, difficulty concentrating, trembling, twitching, irritability, agitation, sweating, restlessness, insomnia, hot flashes, and rashes and inability to fully control the anxiety (Wikipedia). As you can see, there are a lot of physical type symptoms related to GAD. How this may or may not relate to the previously mentioned “psychosomatic illness” is unclear at this point. Should Lubitz have been flying with this problem? It depends on the severity of the symptoms and which ones he was having. Could he have concealed these problems? Possibly, though that probably would have only added to the stress and anxiety.

Next, let’s look at “psychotic episode.” This is not really a diagnosis, but is often part of a diagnosis of some sort of psychotic disorder. In essence, it involves either hallucinations or delusions or both. There are other symptoms often associated with the psychotic episode, but these vary. Is this schizophrenia? It could be, but it could be related to a wide variety of other disorders or causes. This statement about Lubitz having had a psychotic episode tells us only that he had a period of time when he was not really in touch with the reality most of us share. It could have been brief. It could have been a one-off situation, never to recur. It could have been related to medication or physical illness (some illnesses like measles or other infection with high fever can result in hallucinations). Again, as with so much in this case, we just don’t know yet.

Now to talk about the “antipsychotic medication”. These include medications like Haldol, Thorazine, Seroquel, Zyprexa and a slew of others. Drugs like Haldol and Thorazine are often called “typical” antipsychotics, while the others are called “atypical” and are the drugs of choice nowadays. I’d like to know when this medication was prescribed. Back in 2010 or more currently? I guess it could be possible that he had left-over meds from that psychotic episode in 2010. If he was currently on an antipsychotic medication (which I’ve seen used as a sleep aid in patients who were NOT psychotic), that’s a whole different story…...UPDATE: just heard that he was given antipsychotic injections back in 2010 and that antidepressants were found in his apartment.

Once again, we’re left with a lot of questions still about this tragic case. BTW: It’s been my experience that docs often prescribe antidepressant medications for GAD. Also, the FAA (don’t know about the regulations in Germany, any help here would be appreciated) announced it would consider waivers that would allow a pilot taking certain antidepressants to continue flying.

UPDATE 3/30/15:  I heard a report on CNN that back in the 2009/2010 time frame, Lubitz was given Zyprexa. This medication is an “atypical” antipsychotic medication in wide use. It has some serious side effects, including sedation, weight gain, visual problelms, muscle problems, and a whole lot more. On the other hand, it’s very effective for individuals suffering from hallucinations and delusions. No, he wouldn’t have been able to fly while taking this medication.

Mar 29 2015

Psychosomatic Illness

It appears as of this morning, that Lubitz, the Germanwings copilot responsible for the crash in the Alps, was reported as suffering from a “psychosomatic illness.” Just what does that mean? Well, to put it in the simplest terms, it means that his emotions were affecting his physical functioning. For example, stress is well-known to have many physical effects. It is a strong contributor to Irritable Bowel Syndrome. What it does not mean is that it was a “made up” or imaginary illness. As a sufferer of IBS, I can tell you that my multiple trips to the bathroom are not imaginary! 😀

Wikipedia provides this definition (seemly derived from DSM 5): A somatic symptom disorder, formerly known as a somatoform disorder, is a mental disorder characterized by physical symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder. There are several somatic symptom disorders recognized in DSM 5 (Diagnostic and Statistical Manual, edition 5). In essence this definition means that Lubitz likely was presenting with at least one physical symptom that was not explained by a physical cause. We don’t know what symptoms he was reporting.

Just what the nature of Lubitz’ problems were is still unknown. And that’s important here. We just don’t know. I’m sure that the various investigators are looking into what was going on with this young man. But if they want to be thorough and come up with as accurate picture of what was going on with him, then it will take time. This, of course, is a problem for the media which needs to have a near-constant stream of new material, but this is the reality here. Diagnosis of a mental condition is difficult enough in a clinical setting with a cooperative (and alive) patient. And in this case, the investigators aren’t just looking for a diagnosis, but for the reasons for a specific act.

UPDATE 3/30/15:  Heard some psychologist on CNN saying that the reported psychosomatic illness suffered by Lubitz indicated that he was not in touch with reality and that he was psychotic. That’s just plain wrong.

It seems that Lubitz was having visual problems, but docs couldn’t find an organic reason for those problems so suggested that it was psychosomatic. Okay, that can happen. Think back to old WWII movies and soldiers suddenly unable to see but there are no physical wounds. That used to be called “hysterical blindness.” It doesn’t happen as much any more, but it does occur. But, it does not mean the patient is psychotic or out of touch with reality. It means that the psychological stress and upset the patient is suffering from is manifesting through the visual system.

I am also concerned about just who called this a psychosomatic illness. Was it the eye doc after finding nothing physically wrong with Lubitz’s eyes? Hmm. Reminds me of many, many years ago when I was complaining of pain in my knee. This was before CAT scans or MRIs, so when nothing showed up on X-Rays, the orthopedist called it psychosomatic, a way to get out of phys ed at school. Jump forward a couple years and another orthopedist decided to do surgery since at that point I’d been having pain for quite a number of years. Lo and behold, he found a torn cartilage. Bottom line: just because a doc doesn’t find something physically wrong doesn’t mean necessarily that it’s “all in your head.” Thank goodness my docs never suggested that I was psychotic. I wasn’t.

I’d need a lot more information to say whether or not Lubitz was psychotic in the past or at the time of the crash. Just because someone labeled him as suffering from a psychosomatic disorder DOES NOT make him psychotic!

Mar 27 2015

Duty to Warn

I’m seeing on CNN some discussion about what the physician should or should not have done regarding notifying Lufthansa and/or Germanwings about the copilot’s (Lubitz) medical condition and his reported unfitness for “work”.

Here in the US, as a psychologist, I have a “duty to warn” based on various court cases in the past. This duty to warn involves situations during which a client makes a specific, imminent threat against an identifiable individual. This derived from the Tarasoff case. The rulings in this case have been extended over the years. I don’t know what the requirements are for German doctors. If someone knows, please let me know!

So, would a “duty to warn” pertain here? Maybe. Let’s take the case to the US and say the pilot is seeing me. The pilot comes in and reports feeling very depressed. He hasn’t been sleeping. He’s refused medications (because of flying) but has engaged in therapy on a regular basis. Now he reports having some thoughts about wanting to die. I ask if he has a plan. No, he replies. It’s clear to me that he’s depressed and at some risk for suicide, but there’s nothing that would set off alarm bells here. In this case, I’d ask more about his ability to concentrate. I’d try to engage the pilot in a conversation about whether or not he feels able to fly. He says, “I don’t know.” Perhaps in that situation, I’d give him a note that would cover him if he chose not to go in to work.

Now let’s up the ante. Same initial situation, but now he reports some strong feelings of wanting to die. When asked if he has a plan, he looks up with a half smile and says, “I could always crash a plane into some mountains. That’d be the way to go.” His risk for suicide just goes up. He actually has a plan but it’s still vague. He could mean taking a private plane up and crashing it. I think in this scenario, I’d work really hard on getting him admitted to a hospital. But, he’s likely to refuse to do that since it would come to his employer’s attention and likely result in being grounded. This puts me in a real dilemma. If I take away something he loves (flying), am I increasing his level of depression and actually giving him even more reason to suicide? I think I’d put him on a daily call in to me and strongly recommend he take a few days off, perhaps even see me more frequently while he’s on sick leave.

Now, let’s say he says “Doc, I just want to die. I keep thinking about getting into the jet, waiting till the pilot goes to the bathroom, and then crashing the plane into a mountain.” I argue about the other people involved. “Their families will get over it.” or “People die all the time.” I ask when he’s going to do this. “Soon.”  Okay, the threat is imminent and specific enough that I’d feel compelled to do something. True, the victims as individuals aren’t specified, but it’s clear he’s talking about crashing an airliner. Needless to say, I’ve never been in this situation. However, I think, given the laws here in the US and my own morality, I’d act to get him involuntarily committed to a hospital. He clearly (at least to me at that point) is a danger to both self and others. I think I’d also contact his employer, just in case anything fell through and he was released and tried to go back to work. I could be faced with a lawsuit due to break of privacy, but I think I could fight that with the help of a good lawyer.