Local Scottsdale psychiatrist Michael Yasinski M.D discusses the conceptualization of the Colorado shooting from a psychiatric perspective

The Colorado shooting-Interpreting the speculation

As more information emerges about James Holmes and the details of the Colorado shooting, so does the speculation and erroneous comments flooding the media. As an information hungry nation we are fortunate to have access to instant information which can be great in many situations, however can also fuel the flames of uninformed speculation in cases such as this.  With dedicated cable news stations and the opportunity for almost anyone to voice an opinion over the internet, it is difficult to separate the facts from the fiction and it’s impossible to know which “expert” to trust.

As a psychiatrist I cringe at some of the speculation that has been presented and how non-mental health professionals are portraying psychiatric illness.   Even as a psychiatrist who has evaluated and treated many mentally ill individuals, I will not begin to definitively diagnosis this man. I can however clarify some of the erroneous comments and misinformation which can provide some insight into how a psychiatrist may conceptualize this case.

“James Holmes is clearly psychotic.” Many people emphatically stating this without an accurate idea of what the term psychosis means. The term “psychotic” is used by the public to describe anyone who displays relatively bizarre or abnormal behavior but that conceptualization is not accurate. There is a clear meaning to the term which is important to understand and has not been adequately clarified in the media despite the term being used over and over.

To better understand the concept of psychosis, consider this: Have you ever had an extremely vivid and detailed dream that made perfect sense while in the dream but upon waking up realize that the dream made absolutely no sense and was filled with many impossible scenarios? This is a glimpse into the mind of someone experiencing psychosis.  A world filled with unrealistic events, perceptions and behaviors to a healthy individual but a world every bit as real as our dreams often feel to the psychotic person.

“Loss of reality testing” is often a term used to describe psychosis. The loss of reality testing means the loss of the shared world and with it the loss of meaningful communication with others. If a person’s perceptions are so different that they become “unreal” to us, we stop being able to understand what is being said. If a person assigns meanings to a word that bear no similarity to the meanings we assign, then the same words may be used but no meaning is exchanged. The disturbed person becomes isolated because he no longer experiences or understands the world in the way that we do.

The two most common manifestations of psychosis and impaired reality testing are delusions and hallucinations.  Delusions defined as “a belief held with strong conviction despite superior evidence to the contrary.”  Hallucinations as defined as a perceptual disturbance involving hearing voices that only the person can hear and having visions that only the person can see.  While these delusions, voices and visions are not real to the rest of the world, they are absolutely real to the psychotic individual and they have no question about the legitimacy of their experiences.

With a more clear understanding of psychosis, one can appreciate the notion that anyone who is psychotic is unable to carry out an extensive, premeditated plan over the course of weeks or months as absolutely false.  Impairment in parts of the brain involved in perceptions of our surroundings does not necessarily indicate impairment in the part of the brain involved in planning and execution of those plans. Whether or not James Holmes was psychotic is not clear at this point but it certainly cannot be ruled out by the fact he carried out an extensive plan over the course of months.

Another example of erroneous speculation involves the understanding of the term “Sociopath”  Many people have labeled the Colorado shooter as a Sociopath based on a limited understanding of what that actually means.  Although many serial killers and mass murderers are sociopaths, it definetly is not always the case. The diagnostic manual in psychiatry (DSM IV)  defines it as the following:

There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:

  1. 1.     failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
  2. 2.     deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
  3. 3.     impulsiveness or failure to plan ahead;
  4. 4.     irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  5. 5.     reckless disregard for safety of self or others;
  6. 6.     consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
  7. 7.     lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;

There is clearly not enough information available to even speculate whether or not the shooter was a true sociopath.  This does not mean the suspect is not a sociopath or is not an evil, angry person but I feel people are jumping the gun on using a diagnosis which should be reserved for people truly fitting the diagnosis.

A third theme that has emerged after the suspects first court appearance is whether or not he is “faking” his bizarre behavior both before and after the shooting. Body-language experts have even jumped in and commented on their belief he is “faking” the symptoms.  As a psychiatrist who has treated many patients with all sorts of diagnosis, I have witnessed the spectrum of bizarre behavior and body language with no consistent trend in any of them.  Although it is possible, it only adds to the confusion and misperception of psychiatric illness as something that is feigned or made-up which only contributes to the extreme stigma surrounding psychiatric illness that already exists.

What has largely not been discussed is in the public is one of the most important considerations to a psychiatrist in a case such as this. Ruling out an underlying medical illness that can cause extremely bizarre behavior is crucial. Brain tumors, metabolic diseases, and infections are some examples of medical problems that can cause extreme changes in personality, behavior and perception of reality.

Regardless of the ultimate explanation of his motives, one question remains-What could have been done to prevent this?  Politicians quickly jump on gun control or legislation regarding mental health law, however neither of these address the root cause of why these situations continue to happen in our society.

The problem is the stigma attached to psychiatry and negative perceptions of mental illness. If society was more open in discussing mental illness and accepting it as a legitimate medical illness, people who experience early symptoms of a mental illness would be much more likely to seek help before they spiral out of control.  The public would also be more likely to openly discuss concerns about someone rather than feeling it is a taboo subject not to be openly discussed.  The openness in which we talk about cancer, diabetes and heart disease needs to be carried over to mental illness and only then will there be a significant decrease in these horrible tragedies.  The first step in doing so is to properly educate the public rather than speculate about completely inaccurate representations of psychiatric disorders, which unfortunately has been all too common in this case.

Michael Yasinski MD