Mass Murder and Psychiatry

By H. Steven Moffic, MD

There has been increasing publicity about the imminent end of the world on December 21, 2012, as possibly posited in the Mayan Calendar. What we do know for sure, is that for all the young children and adults who were killed in Newtown, Connecticut, their world ended a week earlier, on December 14th.

As the play of the same name by Thornton Wilder, Newtown Is Our Town.

The perpetrator must be, in some way, everyman. We must be our brother's keepers. Any field that can contribute to the understanding and prevention of the increasing numbers of attempted and successful mass murders in the United States must work on this for the next weeks, months, and years. Psychiatry is surely one of these.

Diagnosis

Amidst all the initial speculation on the reasons for the tragedy, my wife noticed an e-mail from a psychiatrist that struck us as possibly revealing deeper issues, some perhaps indirectly relevant. The subject was "Autism not a Mental Illness." Autism was one of the initial diagnoses associated with this killer. Beyond such premature diagnostic speculations, the e-mail was reacting to a CNN coverage in which a physician and a reporter discussed that autism may not be an illness, since NIMH was considering autism and other mental conditions as "neurogenerative." Perhaps, the e-mailer suggested, if autism was not considered to be a mental illness, would that be better because then, if the murderer did not have a mental illness, mental illness could not be blamed for the mass murder.

This argument, though cumbersome, leads us to take a step back and take a bit of a detour. First of all, there are no mental illnesses, at least so far as the terminology goes for the DSM and ICD classifications of mental conditions. This is more important than mere semantics. These conditions are called disorders, not illnesses or diseases. The prime definition of disorders, in my Webster’s dictionary, is "confusion."

However "disorder" is defined, it causes mental conditions to appear to be different from medical illnesses. It implies that clinicians other than psychiatrists can be expert in the diagnosis and treatment of those disorders. Indeed, that is one of the issues that I was concerned about in the March 10, 2010 blog, "The DSM Process: More Questions Than Answers." The cautionary statement as to who can make a diagnosis reads: "It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses occupational and rehabilitation therapists and counselors."

So much for the medical expertise of psychiatrists in making a diagnosis. As far as I know, that consideration will not change in the upcoming DSM-5.

This is a scenario that is more likely to lead to an inadequate diagnosis or missed diagnosis. Moreover, diagnosis, though necessary for reimbursement, research, and a general sense of what is wrong, should only be the necessary, but not sufficient, step in understanding an individual. Adequate time and analysis is required. As the bio-psycho-social model implies, we have to look far and wide to try to understand anyone. If indeed the perpetrator of the Newtown tragedy fell on the Autism spectrum, how often does a mass murderer have that diagnosis?

Guns

As so many have commented, the ease of obtaining automatic weapons can indeed contribute to mass destruction. If someone has untreated mental problems, the risk also increases. Adding guns and knowing how to use them, to someone with apparent mental problems, surely increases the odds of something bad happening.

Any positive reinforcement of gun use, outside of controlled situations such as hunting, may cause more unnecessary harm than benefit. Certainly, we have a lot of positive reinforcement and modeling of a gun culture in our Constitution, our seemingly endless war, and violence in the media. The more impersonal ways of relating on the internet may veer us more toward the social deficits and lack of empathy that is characteristic of the Autism spectrum.

Evil

I never used the term evil professionally or personally until I worked in prison part time at the end of my clinical career. For many of the inmates I saw, mental disorders, including substance abuse, seemed to play a significant role in their crimes. Gang involvement, where self-esteem and identity, was enhanced through group process, was another significant factor for many. On a rare occasion, neither a mental disorder, including antisocial personality disorder, nor gang behavior, seemed to be enough of an explanation.1 That is when I began to think more seriously of evil, as did many in the aftermath of this recent tragedy. The Governor of Connecticut claimed that "evil visited this community . . . ." Later he expanded that to mental illness dressed in evil. Perhaps that can be further expanded to mental illness dressed in evil and a holster.

Recommendations

Soon after the tragedy, one of the fathers of a child killed tearfully pleaded for society to learn from what happened in order to prevent future mass murders. Here's what I think psychiatry can contribute:

  • Autism, Asperger, and most every other mental condition worthy of our prime focus should be called diseases, not disorders
  • All such diagnoses should be made or certified by a psychiatrist to qualify for medical insurance coverage
  • Do not make public diagnoses of anyone not personally examined, per our Goldwater Rule
  • This tragedy, following too many others, should spur further study of where criminal behavior ends and psychiatric disease begins, if indeed there is even such a line
  • All psychiatrists should spend some clinical time in a correctional institution, either during residency or later for continuing education
  • Find better ways to educate the public about the early signs of homicidal risk
  • Advocate for a system of safe reporting of those felt to be at- risk for homicidal behavior
  • Provide better resources in order to improve early treatment of homicidal ideation
  • Convene a representative body of those injured by public violence and loved ones of those murdered, to work on a national Task Force to reduce mass murder
  • Advocate for a special anniversary date or holiday, December 14th, to not only remember the Connecticut tragedy or others like it, but also as a way to monitor how we are doing as a nation and a profession in trying to prevent more such tragedies.

Reference

1. Moffic HS. Better Off in Prison; 2011. Psychiatric Times. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1850954. Accessed December 17, 2012.

Dr. Robert Jay Lifton Honored

Dr. Robert Jay Lifton was honored by the American Association for Social Psychiatry with the Humanitarian Award at the May Meeting of the American Psychiatric Association in Philadelphia on May 7, 2012. Dr. Lifton was recognized for his devotion to promoting the social dimension of our work as psychiatrists.Dr. Lifton's recent book, Witness to an Extreme Century, is a must read. Participants at the award presentation included R Rao Gogineni, M.D., Abraham Halpern, M.D, Robert Jay Lifton, M.D., Steven Sharfstein, M.D., Steven Moffic, M.D., Driss Moussaoui, M.D, and Henri Parens, M.D.

Medical Students’ Comfort With Pregnant Women With Substance-Use Disorders: A Randomized Educational Study

Brittany Albright, M.D., M.P.H.; Betty Skipper, Ph.D.; Shawne Riley, B.A.; Peggy Wilhelm, R.N.; William F. Rayburn, M.D., M.B.A.
Academic Psychiatry 2012;36:457-460.10.1176/appi.ap.11070134

Abstract

Objective: The study objective was to determine whether medical students' attendance at a rehabilitation residence for pregnant women with substance-use disorders yielded changes in their attitudes and comfort levels in providing care to this population.

Methods: This randomized educational trial involved 96 consecutive medical students during their obstetrics and gynecology clerkship. In addition to attending a half-day prenatal clinic designed for women with substance-use disorders, every student was randomly assigned either to attend (Study group) or not to attend (Control group) a rehabilitation residence for pregnant women with substance-use disorders. The primary objective was to measure differences in responses to a confidential 12-question survey addressing comfort levels and attitudes, at the beginning and end of the clerkship.

Results: Survey responses revealed improvements in students' comfort levels and attitudes toward pregnant women with substance-use disorders by attending the clinic alone or the clinic and residence. Those who attended the residence reported becoming more comfortable in talking with patients about adverse effects from substance abuse, more understanding of "street" terms, and stronger belief that patients will disclose their substance use to providers. Residents expressed more openly their hardships and barriers while trying to set therapeutic goals.

Conclusions: Medical students became more comfortable and insightful about pregnant women with substance-use disorders after attending a rehabilitation residence in addition to a prenatal clinic dedicated to this population.

(see article on Academic Psychiatry)

Professor RS Murthy Receives Juan José López Ibor Award for 2012

We are very happy to inform, our Senior Fellow Professor RS Murthy has been awarded the coveted Juan José López Ibor Award for 2012.  The Award  was created by The Juan José López-Ibor Foundation in order to recognize and honour individuals or institutions that made significant scientific contributions leading to a better understanding of psychiatric diseases while being actively engaged in activities enhancing the human dignity of patients and their families. The Award, which is granted every two years, rewards initiatives of research, study, promotion, and communication carried out by individuals or institutions. It consists of a diploma, a token, and 40,000 Euros.

Our heartiest congratulations to Prof Murthy for this great honour, which he has so richly deserved.

Psychiatric Eulogies for Psychiatrists Who Inspired

By H. Steven Moffic, MD

It must be my age. . . or retirement. . . or my Rabbi son attending so many funerals. Because I paid especially close attention to the "In Memoriam" list in the August 3, 2012 issue of Psychiatric News-- the APA's official news publication.

The subtitle was "APA honors the following members whose deaths were reported April 1, 2011 to March 31, 2012." I wondered what was meant by "honors," given that only the names of the deceased were listed. Though hard copy space is increasingly hard to come by these days, it still seems fitting to include something brief and positive about the career of the deceased. You know. . . a short tribute to their labors and lasting contributions . . . a miniature psychiatric eulogy.

As I read the names, I realized I knew -- in one way or another -- quite a few of those listed. Maybe you do, too? In the brief comments that follow, in alphabetical order, here is how I would honor their lives as psychiatrists. If you’d like to add your comments to mine, you are welcome to do so in the comment box below. 

Doris A. Berlin, MD (aka Dr Doris Berlin-Acker)

When I began my medical career 40 years ago, psychiatry, particularly the psychoanalytic field, was about the only medical specialty in which women were prominent. Dr Berlin was one of those early women psychiatrist pioneers, especially in my beloved area of community psychiatry.

Paul E. Chodoff, MD

Dr Chodoff was an unseen mentor to me of sorts. His important work on the psychological effects of the Holocaust, psychiatric ethics, and the need to support psychiatrist political dissenters, were early areas of concern for me. I learned much from his writings.

Alfred M. Freedman, MD

Dr Freedman became President of the APA during my psychiatric residency years and led the landmark movement to declare that homosexuality was not a mental illness. He was also a strong proponent of community and social psychiatry; he created a program for addicts in East Harlem in 1959, where such programs did not exist. His broader expertise was apparent as co-editor for the long time standard and monumental text, Comprehensive Textbook of Psychiatry.

Jack E. Geist, MD

Not nearly as well known nationally as Drs Berlin, Chodoff, and Freedman, Dr Geist was nevertheless a giant in the private practice of psychiatry in Milwaukee for 50 years. He was winding down when I moved to that city, but I thought that if most psychiatrists in the area were as gentle, warm, and kind as he, that I would love being here.

Leston L. Havens, MD

Most psychiatrists know of the unique and influential ideas that Dr Havens presented on the psychotherapeutic process, including with psychotic patients. On death itself, he once wrote:
"Death is like great beauty, fame, or money in the self-consciousness it pulls from the observer."

Stuart Keill, MD

Although he was well-known for his administrative expertise, making a major contribution to the landmark "Textbook of Administrative Psychiatry," what I remember most fondly were his presentations on "Madness in Opera" at the annual APA meetings in the 1980s. He even had at least 2 records on the subject. He died on Sunday, March 25, 2012, so might have just missed the APA deadline for last year. On that day, my wife and I saw Aida at the Lyric Opera of Chicago. In retrospect, I'll dedicate that performance to Stu.

Ari Kiev, MD

It is hard to believe that one psychiatrist could make all the contributions to the field that Dr Kiev did. He was a master at investigating and understanding all varieties of culture--from ethnic groups to athletes to Wall Street traders. His book Magic, Faith and Healing was a well-worn and underlined guidepost for me in my early fascination with cross-cultural psychiatry. His thirst for knowledge even led him to earn a law degree in 1988--a path I too briefly considered, but dropped.

Sheldon Miller, MD

Dr Miller was the Chair of the Department of Psychiatry at Northwestern for many years, after being a leader in the establishment of the subspecialty of addiction psychiatry.

Melvin Sabshin, MD

Anyone even remotely knowledgeable about the APA as an organization is, of course, familiar with Dr Sabshin, the long-term Medical Director, who successfully led the expansion of American psychiatry.

Herbert S. Sacks, MD

Another former President of the APA, Dr Sacks turned out to be a (usually) friendly debater with me on the merits (my view) and demerits (his view) of managed care. Although I don’t have any idea if this accounts for the differences in our opinions, he was the son of a Rabbi, and I am the father of a Rabbi.

Herbert Spiegel, MD

The prominent father of the prominent psychiatrist David Spiegel, MD, Spiegel senior was an early advocate for the scientific use of hypnosis.

Thomas T. Tourlentes, MD

Dr Tourlentes became a leader in community psychiatry not only nationally, but in his local community of Galesburg, Illinois. Reflecting his national and local interests, he was a President of the American Association of Psychiatrist Administrators, as well as of the Knox-Galesburg Symphony. He must have been exactly what President Kennedy had in mind to lead the development of community mental health.

In passing, I noticed the ages of the psychiatrists I knew. Half were in their 90s and the average age in the upper 80s. Is this just by chance or is there something about being a psychiatrist that helps us to live longer? I hope it’s the latter.

R.I.P. Rest Inspiring Psychiatrists. I am grateful for having known you.

Eliot Sorel's "21st Century Global Mental Health" Now Available

21st Century Global Mental Health is a comprehensive and authoritative text on the subject of global mental health and its integration with public health and primary care. The book thoroughly examines the progress to date and the challenges that still remain. In five sections, it explores:

  • Global Mental Health Epidemiology and Diagnostic Systems
  • The Determinants of Health/Mental Health
  • Populations' Health/Mental Health
  • Evaluating and Strengthening Health/Mental Health Systems
  • Human Rights, Stigma, Mental Health Policy and the Media.

Click here to download the flyer.

About the Editor

Eliot Sorel, MD, DLFAPA, is an internationally recognized global health leader, educator, health systems policy expert and practicing physician. He is co-chairman of the non-communicable diseases (NCDs) and integrated care task force of the World Psychiatric Association and co-chairman of the scienti!c committee of the WPA 2013 Bucharest Congress on integrating primary care, mental health and public health for Eurasia and Southeast Europe. He holds professorial appointments in Global Health, Health Services Management and Leadership in the School of Public Health as well as in Psychiatry and Behavioral Sciences in the School of Medicine at George Washington University.

Dr. Sorel is the Founder of the Conflict Management & Conflict Resolution Section of the World Psychiatric Association and of the World Youth Democracy Forum at the Elliott School of International Affairs of the George Washington University. He is the Senior Adviser to the Ion Ratiu Democracy Award (IRDA) at the Woodrow Wilson International Center for Scholars in Washington, D.C. 

Dr. Sorel is a former President of the Medical Society of the District of Columbia, the World Association for Social Psychiatry, the Washington Psychiatric Society and has served as a United States National Institutes of Health/Fogarty International Center grants reviewer. He is a Life Member of the American Medical Association, a Fellow of the American College of Psychiatrists, and a Distinguished Life Fellow of the American Psychiatric Association.

In July 2010, Dr. Sorel convened the Black Sea & Caspian Sea Area Studies Network, a Euro-Atlantic, universities partnership that developed the Bucharest Consensus on Higher Education, Innovation & Development. In June 2008, he participated as PAHO/WHO advisor, in the WHO Europe Health & Finance Ministers' meeting on Health Systems, Health & Wealth in Tallinn, Estonia, that rati!ed the Tallinn Charter. 

In October 2009, Dr. Sorel was awarded the Doctor Honoris Causa by Carol Davila Medical University in Bucharest, Romania. The President of Romania awarded Dr. Sorel the Star of Romania Order of Commander in 2004.

Steven Moffic's Starts new blog, Sad in Psychiatry

Steven H. Moffic's new blog, Sad in Psychiatry, is now online on Robert Whitaker's Mad in America website.  Mr. Whitaker wrote the book Anatomy of an Epidemic, which has caused an uproar due to its caution about the long-term use of most psychiatric medications.

Sad in Psychiatry: Affectionately called a "gadfly," and  known as "da man in psychiatric ethics," Steven Moffic writes about what makes him sad about modern day psychiatry, and how to "treat" that condition so that we will become glad about what psychiatrists can do to help. 

www.madinamerica.com

Non-communicable diseases (NCDs) and Integrated Care: Contemporary, American & Global Challenges

Eliot Sorel, M.D., D.L.F.A.P.A

Eliot Sorel, M.D., D.L.F.A.P.A., is an internationally recognized medical leader, educator, health systems policy expert and practicing physician. He is co-chairman of the non-communicable diseases (NCDs) and integrated care task force of the World Psychiatric Association and co-chairman of the scientific committee of the WPA 2013 Bucharest Congress on integrating primary care, mental health and public health for Eurasia and Southeast Europe, strengthening health systems, to take place in Bucharest, Romania in April 2013, accessible at www.wpa2013bucharest.org. Dr. Sorel is the Founder and Chairman of the Career, Leadership and Mentorship Program of the Washington Psychiatric Society. He has professorial appointments in Global Health, Health Services Management and Leadership in the School of Public Health as well as in Psychiatry and Behavioral Sciences in the School of Medicine at George Washington University. Dr. Sorel is the Founder of the Conflict Management & Conflict Resolution Section of the World Psychiatric Association and of the World Youth Democracy Forum at the Elliott School of International Affairs of the George Washington University. He is the Senior Adviser to the Ion Ratiu Democracy Award at the Woodrow Wilson International Center for Scholars in Washington, D.C.

Dr. Sorel is a former President of the Medical Society of the District of Columbia, the World Association for Social Psychiatry, the Washington Psychiatric Society and has served as a United States National Institutes of Health/Fogarty International Center grants reviewer. He is a Life Member of the American Medical Association, a Fellow of the American College of Psychiatrists, and a Distinguished Life Fellow of the American Psychiatric Association. He did his psychiatric training at Yale University, obtained his B.A. from New York University, and M.D. from the State University of New York. He has developed and led health systems in North America and the Caribbean, has consulted and taught in more than twenty countries in Africa, Asia, Europe and the Americas. Dr. Sorel is the author of more than sixty scientific papers and book chapters and the editor of six books. His most recent scientific paper, The Integration of Psychiatry & Primary Care was published in the International Review of Psychiatry, in February 2011 and his most recent book, The Marshall Plan: Lessons learned for the 21st century was published by OECD in Paris in 2008, is accessible at www.oecd.org.

In July 2010, Dr. Sorel convened the Black Sea & Caspian Sea Area Studies Network, a Euro-Atlantic, universities partnership that developed the Bucharest Consensus on Higher Education, Innovation & Development. In June 2008, he participated as PAHO/WHO advisor, in the WHO Europe Health & Finance Ministers' meeting on Health Systems, Health & Wealth in Tallinn, Estonia, that ratified the Tallinn Charter.

In October 2009, Dr. Sorel was awarded the Doctor Honoris Causa by Carol Davila Medical University in Bucharest, Romania. The President of Romania awarded Dr. Sorel the Star of Romania Order of Commander in 2004. 

Welcome to Social Psychiatry

The American Association for Social Psychiatry is very excited and pleased about the inauguration of our website. AASP, founded by Dr. John Schwab, has been in existence since 1971. The mission of AASP is to study, teach and promote consciousness of social factors in the psychiatric disorders of our patients and promote an understanding that social factors are core to all behavioral health issues. Since its inception AASP was presided by socially conscious social psychiatry and psychiatry leaders: John J. Schwab, Milton Greenblatt, John J. Carleton, Paul L. Adam, Stanley Dean, Alvin Friedland, Robert Cancro, Gene Usdin, Harold M. Visotsky, Robert L. Leon, Gerald Sarwer-Foner , Roger Peele, Leah Dickstein, Steven Moffic, Pedro Ruiz, Abraham Halpern, Larry Hartmann, Zebulon Taintor, Steven S. Sharfstein, Beverly Fauman, and Charles Huffine. Many of them, and other affiliate AASP members have published and presented on important social psychiatric topics like trauma, immigration, influence of technology and managed care on psychiatry, violence, etc.

The current AASP leadership decided to join our world body, the World Association for Social Psychiatry (WASP) to connect internationally and to allow all our AASP members to become members of WASP. We also decided to bring the organization up-to-date and establish a state of the art website for access to members and those interested in social psychiatry. We are planning to start an ejournal. 

APA accepted all four of our submissions to the annual meeting to be held in Philadelphia May 5-9, 2012. The major theme of this year’s presentations is humanism and human rights. We are proud of bestowing our 1st Humanitarian Award on Robert J. Lifton, M.D. on May 7th during the APA Meetings. 

AASP is dedicated to addressing various social psychiatric issues of all our patients, minorities, women, immigrants, LGBT, families, children, adolescents, young  adults, older adults, etc. and promoting "social" in psychiatry. 

We invite you to join us and promote our AASP.