Psychiatric Annals

CME 

Psychotic Rampage Murderers, Part II: Psychotic Mania, Not Schizophrenia

C. Ray Lake, MD, PhD

Abstract

This provocative and controversial article addresses efforts at prevention of lethal psychotic rampages by challenging the long-established medical concept that functional psychosis means a diagnosis of schizophrenia. Schizophrenia has been the diagnosis given to most psychotic mass murderers, but detailed media reports of the perpetrators’ behaviors, when available, have suggested states of psychotic mania, defining a bipolar disorder, not schizophrenia. Psychotic killers murder more than 1,000 innocent victims, including children, each year, usually with firearms; however, efforts at prevention must go beyond gun control and include focus on the severely mentally ill. Psychiatry has an opportunity to more effectively intervene regarding diagnostics, treatment, and restraint in cases who come into contact with mental health facilities prior to their rampages.

Bipolar disorder is a bona fide medical disease with strikingly specific diagnostic criteria that includes psychosis in half of severe cases, thus accounting for many cases diagnosed with schizophrenia. Seven typical cases have been detailed in this paper to support these opinions. All were diagnosed with schizophrenia despite reports of multiple symptoms suggesting psychotic mania. Manic patients misdiagnosed with schizophrenia do not receive standard-of-care treatment, resulting in suboptimal efforts at prevention and increasing the risk for medical malpractice liability. Litigation can change psychiatric diagnostic practices.

Abstract

This provocative and controversial article addresses efforts at prevention of lethal psychotic rampages by challenging the long-established medical concept that functional psychosis means a diagnosis of schizophrenia. Schizophrenia has been the diagnosis given to most psychotic mass murderers, but detailed media reports of the perpetrators’ behaviors, when available, have suggested states of psychotic mania, defining a bipolar disorder, not schizophrenia. Psychotic killers murder more than 1,000 innocent victims, including children, each year, usually with firearms; however, efforts at prevention must go beyond gun control and include focus on the severely mentally ill. Psychiatry has an opportunity to more effectively intervene regarding diagnostics, treatment, and restraint in cases who come into contact with mental health facilities prior to their rampages.

Bipolar disorder is a bona fide medical disease with strikingly specific diagnostic criteria that includes psychosis in half of severe cases, thus accounting for many cases diagnosed with schizophrenia. Seven typical cases have been detailed in this paper to support these opinions. All were diagnosed with schizophrenia despite reports of multiple symptoms suggesting psychotic mania. Manic patients misdiagnosed with schizophrenia do not receive standard-of-care treatment, resulting in suboptimal efforts at prevention and increasing the risk for medical malpractice liability. Litigation can change psychiatric diagnostic practices.

Although once controversial, psychotic mental illness has been strongly associated with increased violence, especially when untreated and accompanied by paranoid, persecutory delusions, command auditory hallucinations, and substance abuse.1–5 Hallucinations and delusions define psychosis and are a reality for the psychotic individual. Psychotic individuals have grandiose and paranoid delusions and often they think that they are being watched, followed, bugged, and threatened, typically by individuals or organizations of great consequence (ie, grandiose). The paranoid delusions generally include grandiosity that indicates mania in a psychotic individual6–8 (Figure 1). When paranoid, these individuals can be in desperate fear for their lives and act accordingly, thinking they must kill to protect themselves, their family, and their country, or to prevent some grandiose world catastrophe. The recently published Diagnostic and Statistical Manual, Fifth Edition (DSM-V) describes two major diagnoses that account for primary psychosis: schizophrenia and severe mood disorders (for example, mania that defines a bipolar disorder, type I).9 This differential deserves to be a central focus of efforts at prevention of future mass slaughters.

Paranoia hides guilt and grandiosity. Psychotic mood disorders, not schizophrenia, cause paranoid delusions leading to rampage violence and mass murders.Figure courtesy of C. Ray Lake, MD, PhD.

Figure 1.

Paranoia hides guilt and grandiosity. Psychotic mood disorders, not schizophrenia, cause paranoid delusions leading to rampage violence and mass murders.

Figure courtesy of C. Ray Lake, MD, PhD.

Despite the close association of mania-specific grandiosity with paranoia6,7 (Figure 1), the mis-association of violence, specifically with schizophrenia rather than mania and depression, is strong: 1) After two rampage murder episodes in Utah in 1999, a “crackdown on schizophrenia was urged” in the media,10,11 2) An April 2000 New York Times article reviewed 100 cases of psychotic rampage killers.1,2 About half of the killers received a formal diagnosis either before or after their rampages, which was almost always schizophrenia. 3) In 2009, an article was published titled, “Schizophrenia and Violence: Systematic Review and Meta-Analysis.”3

The misconception that psychotic mass killers suffer from schizophrenia, not bipolar disorder, is further substantiated by the recently published opinions of three imminent American psychiatrists regarding Mr. Alexis, the September 2013 Washington, D.C. Navy Yard mass murderer (Table 1). Their diagnostic assessments raise issues regarding the Goldwater Rule,12,13 but speculations about diagnosis in efforts at prevention of future rampage murders is entirely justified in this author’s opinion. In his National Review online piece, Charles Krauthammer, MD,13 said in reference to Mr. Alexis in that his “delusions, paranoid ideation, auditory (and somatic) hallucination: [are] the classic symptoms of schizophrenia.” A recent President of the American Psychological Association (APA) and current Chairman of Psychiatry at Columbia University, School of Medicine, Jeffrey Lieberman, MD, and E. Fuller Torrey, MD, Executive Director of the Stanley Medical Research Institute and founder of the Treatment Advocacy Center, were interviewed on “60 Minutes” after Mr. Alexis’ Navy Yard massacre. Dr. Torrey said, “About half of these mass killings are being done by people with severe mental illness, mostly schizophrenia.”15 Drs. Lieberman and Torrey are correct with regard to the high prevalence of severe mental illness among mass murderers, the inadequate state of the care of such psychotic patients in the U.S., and that psychosis is caused by a disease of the brain.

Summary of Manic Symptoms in Lethal Rampage PerpetratorsSummary of Manic Symptoms in Lethal Rampage Perpetrators

Table 1.

Summary of Manic Symptoms in Lethal Rampage Perpetrators

Bipolar disorders and their relationship to violence have also been reviewed.16 Among homicides of family members committed by patients with a bipolar disorder, one report found that more lethal rampages occurred in the depressed than in the manic phase.16

The overriding issue is from which disease of the brain are these mass killers suffering: schizophrenia or bipolar disorder? Getting it right is critical.

The Validity of Schizophrenia Versus Bipolar Disorder: the Correct DSM Diagnosis is Critical in Prevention

Schizophrenia has been diagnosed in the perpetrators of mass murders because of the century-old misconception that hallucinations, delusions, disorganization, dysfunctionality, chronicity of course, and an early age of onset are diagnostic of a specific disease: schizophrenia. We have been taught that schizophrenia is a different disease than a psychotic bipolar disorder based on the assumption that these symptoms, psychosis and chronicity, are disease-specific for schizophrenia and trump the diagnosis of a bipolar disorder. These misconceptions of a dichotomy of two diseases to account for primary or functional psychoses were initiated in the late 1800s and early 1900s, most notably by Paul Eugene Bleuler (1911, 1950) and Emil Kraepelin (1913, 1919), although Kraepelin later seemed to reverse his initial conclusion that there are two separate diseases.7,8,18

Pope and Lipinski19 were one of the earlier groups in the U.S. in the modern era to challenge this concept of a dichotomy. They recognized that hallucinations, delusions, disorganization, and catatonia — DSM diagnostic criteria for schizophrenia — occur commonly, in more than 50% of cases of severe mood disorders, and that many, if not most, patients with schizophrenia actually suffer with a psychotic mood disorder.19–21 Paranoid delusions, once thought diagnostic of paranoid schizophrenia, derive from the delusional grandiosity of severe mania or the delusional guilt of psychotic depression (Figure 1).6–8,18 Paranoia tends to obscure the grandiosity of mania and the guilt of depression. Recognition of the grandiosity implied by paranoid delusions is important to the diagnosis of a psychotic mood disorder rather than schizophrenia, thus suggesting that a single disease (a mood disorder) explains functional psychoses, not a dichotomy.18 Patients with very severe mood disorders are psychotic.18

Supportive of a single psychotic disease are myriad clinical and basic science research results from multiple disciplines finding surprising but substantial similarities and overlap between patients diagnosed with schizophrenia versus a psychotic bipolar disorder, evoking confident speculation by some that many, if not all, patients with schizophrenia are misdiagnosed and actually suffer with a psychotic mood disorder (Figure 2).8,17 Paranoid schizophrenia, the most common subtype, has been equated with psychotic mania and/or depression and has been appropriately dropped as a subtype from DSM-V.6–9

Diagnoses for psychotic mass murderers: psychotic mood disorders. Before the 1850s there was no dichotomy. The dichotomy began when Kraepelin and Bleuler established the new disease termed “schizophrenia” (SZ). As shown by the circle sizes, schizophrenia became the dominate diagnosis over bipolar disorders (BP) for functionally psychotic patients. This occurred rapidly during the early 1900s and continued well into the 1960s. Although Kasanin in 1933 initiated yet a third diagnosis for psychotic patients, termed “Schizoaffective disorder” (SAD), this diagnosis did not become popular until the late 1960s through the 1980s and 1990s. Schizoaffective disorder became very popular as a diagnosis for psychotic patients with mood abnormalities. Initially, clear zones of rarity were described between schizophrenia, schizoaffective disorder, and bipolar disorders. Schizoaffective disorder is a psychotic mood disorder. Surprisingly, schizoaffective disorder remains in the DSM-5. A continuum or dimensional concept was developed during the 1980s and continues to be popular. Crow has been a major proponent of this theory, which joins all three diagnoses together. Extending the continuum concept, some have proposed that a single disorder, a psychotic mood disorder, explains all of the functional psychoses. It is suggested that this “one-disease model,” a psychotic mood disorder, will eliminate the need for the diagnoses of schizophrenia and schizoaffective disorder. (Modified from Lake.18)

Figure 2.

Diagnoses for psychotic mass murderers: psychotic mood disorders. Before the 1850s there was no dichotomy. The dichotomy began when Kraepelin and Bleuler established the new disease termed “schizophrenia” (SZ). As shown by the circle sizes, schizophrenia became the dominate diagnosis over bipolar disorders (BP) for functionally psychotic patients. This occurred rapidly during the early 1900s and continued well into the 1960s. Although Kasanin in 1933 initiated yet a third diagnosis for psychotic patients, termed “Schizoaffective disorder” (SAD), this diagnosis did not become popular until the late 1960s through the 1980s and 1990s. Schizoaffective disorder became very popular as a diagnosis for psychotic patients with mood abnormalities. Initially, clear zones of rarity were described between schizophrenia, schizoaffective disorder, and bipolar disorders. Schizoaffective disorder is a psychotic mood disorder. Surprisingly, schizoaffective disorder remains in the DSM-5. A continuum or dimensional concept was developed during the 1980s and continues to be popular. Crow has been a major proponent of this theory, which joins all three diagnoses together. Extending the continuum concept, some have proposed that a single disorder, a psychotic mood disorder, explains all of the functional psychoses. It is suggested that this “one-disease model,” a psychotic mood disorder, will eliminate the need for the diagnoses of schizophrenia and schizoaffective disorder. (Modified from Lake.18)

The concept that a chronic and persistent psychotic dysfunctionality is pathognomonic of schizophrenia has also been revised. After long-term follow-up of classic bipolar patients at the National Institute for Mental Health (NIMH) for years to decades, Frederick K. Goodwin, MD,20,21 and Robert M. Post, MD,22 among others, have documented that classically cycling bipolar disorders can deteriorate to a chronic, psychotic, non-cycling state of persistent dysfunctionality. For a classic bipolar disorder, the initial average age of onset occurs in the late teens. Psychotic manic and depressed patients can exhibit all DSM-V diagnostic criteria of schizophrenia.9,18 It is severe mania that is associated with insomnia; hyperactivity; excessive speech and writing; paranoid and grandiose, often politically seasoned, delusions; irritability; anger; rage; and poor judgment and violence, including suicide (in depression or mixed mania), homicide, and lethal rampages. Perpetrator suicide in almost half the cases suggests major depression, bipolar or unipolar, or mixed mania — ie, a mood disorder. These symptoms have been reported in many cases of mass murderers (Table 1).

In contrast to schizophrenia, the diagnostic criteria for mania that define a bipolar disorder are disease-specific and do not include hallucinations and delusions, which are used only to grade the severity of the bipolar disorder.9,18,20,21,23 To establish a bona fide medical disease that has no as-yet-identified organic pathology, diagnostic symptoms must be unique and consistent over time. First and most critical, the signs and symptoms of a classic bipolar disorder are so striking (in contrast to the non-bipolar population) with repeating cycles of mania and depression in the same individuals that classic patients are reliably identified, followed, and studied. Such cycling has been recognized for 2,000 years.20,21 Goodwin and Jamison20 summarized a chronological history of manic-depressive insanity/bipolar disorder: “Medical conceptions of mania and depression are as old as secular medicine itself. From ancient times to the present, an extraordinary consistency characterizes descriptions of these conditions. Few maladies in medical history have been represented with such unvarying language. … [so that] the essential features are recognizable in the medical literature through the centuries. ….”

In bipolar disorders, mania usually occurs in episodes interspersed with more periods of depression and varying times of euthymia. During euthymia, some of these individuals are quite functional and lead generally productive lives with jobs, families, and friends. Some of the most successful and famous individuals throughout history and from all professions have suffered with bipolar disorder. In several of the cases discussed below, there were times of school, job, and relationship stability for months to years before their rampages, sometimes interspersed with non-lethal psychotic, violent episodes likely during other manic episodes (Table 1).

Mass murders perpetrated by psychotic manic individuals have been recorded since early history. In 150 CE, Aretaeus of Cappadocia observed that, “Some patients after being melancholic [depressed] have fits of mania … described as furor, excitement, and cheerfulness.” Aretaeus accurately described bipolar cycling and may be the first to record a rampage slaughter by a psychotic manic individual: “When the depressive phase is over, such patients go back to being gay, they laugh, they joke, they sing … sometimes they laugh and dance all day and all night … sometimes they kill and slaughter the servants.” Aretaeus also associated a paranoid psychosis with mania.20

Cases

Seven cases, typical of dozens if not hundreds of lethal rampage acts, were selected for detailed descriptions here because they demonstrate that psychotic lethal behavior has been attributed to schizophrenia despite media descriptions of the perpetrators’ behaviors that rather suggest a psychotic mood disorder.1–3,24,25 Media descriptions derive from reviews of medical, psychiatric and court records, as well as interviews with the police, attorneys, victims, the killers’ families, friends, teachers, and the killers themselves, when possible, that have provided detailed descriptions of the killers’ thoughts, behaviors, and actions in the hours to years prior to the rampages. When adequately detailed, these descriptions suggest the diagnosis of psychotic mania rather than schizophrenia (Table 1). Effective intervention demands a correct diagnosis.

Miriam Carey, between the White House and the Capitol Building; Washington, D.C.; October 3, 2013

Carey, age 34, made an apparent spur-of-the-moment decision on a Thursday morning to drive 265 miles from her home in Connecticut to the White House in Washington, D.C. with her 18-month-old daughter strapped in the back seat. Carey’s mother said that she thought her daughter was taking her toddler to a doctor’s appointment in Connecticut on Thursday and her sister said, upon hearing of the rampage, that Carey “would not be in D.C. … She was just in Connecticut … I just talked to her.” However, the idea to confront President Obama had likely been considered by Carey for weeks. Although insomnia, racing thoughts, and excessive speeding during the trip to D.C. and earlier were not documented, reckless speeding and likely racing thoughts certainly occurred at and between the White House and the Capitol. Driving directly from Connecticut to the White House, unprovoked and without apparent explanation, she recklessly attempted to break her way into the White House grounds by trying to drive through a metal barricade, striking a uniformed Secret Service Officer. She then sped off down Constitution Avenue toward the Capitol Building at 80 mph (25 mph limit), ignoring red lights and efforts by trailing Secret Service officers to pull her over with their lights flashing, sirens blaring, and guns firing. An observer said of the procession that he thought it was the President’s motorcade; he did not notice the gunfire. Carey’s actions and behavior can be described as frantic and she was likely terrified, sustaining at least two episodes of gun fire into her car. Near the Capitol, her car became stuck and she was shot to death in a hail of gun fire. This bizarre episode is entirely compatible with psychotic mania based on her history. Miraculously no one else, including her 18-month-old in the back seat, was injured.25

Her recent and past histories demonstrate psychosis, grandiosity, and paranoia. There was warning prior to her rampage; her boyfriend was so concerned that he called the local police to report her delusions that President Obama had bugged her apartment and was stalking her. He added that she thought she was a Prophet. These paranoid and grandiose delusions likely explain her trek to the White House. About 18 months before, Carey was hospitalized with postpartum psychosis, which can be an initiating component of a bipolar disorder. Her mental health status during the previous 10 months was described as “ups and downs, [a] serious degradation in her mental condition.” A few years prior, a neighbor observed Carey inappropriately “outside her mother’s Brooklyn apartment clutching a Bible and wailing at the sky.” She was said to have been quoting scripture. In August 2012, she was fired from her dental hygienist position because “she had a temper and was not getting along with her coworkers.” A Homeland Security investigation of Carey’s medical records revealed that she had been diagnosed and treated for schizophrenia. Antipsychotic, but no mood-stabilizing, medications were found in her apartment, which was otherwise unremarkable.25

She had performed on a high level in college and as a dental hygienist, and according to others, did not appear to be unstable. A neighbor found Carey “likeable, very well spoken, and obviously educated.” Another neighbor noted that, “she kept her shiny, black Infiniti very clean and in good shape.”26–28

Her psychotic episodes, marked with grandiose and paranoid delusions; reckless, frantic activities; and past episodes of severe depression, irritability at work, and stable time during which she functioned quite well are consistent with a cycling bipolar, type I disorder (Table 1).

Aaron Alexis, at the Navy Yard; Washington, D.C.; September 16, 2013

Just after 8:00 a.m. on a Monday, Aaron Alexis, age 34, a former Naval Reservist and a Navy contract employee, drove his rental car to his work assignment and, with his Department of Defense (DOD) security clearance and newly purchased Remington pump-action shotgun, entered the Washington Navy Yard on the banks of the Anacostia River, a few miles from the White House, and killed 12 people. Alexis was killed by police after a gun fight (ie, “suicide by cop”).29–32

The media reported that “federal and local authorities have interviewed hundreds of people and are pouring through the contents of Alexis’ Yahoo email account.” Alexis’ past history suggests cyclic episodes of poor judgment, violence, and likely psychosis, as well as euthymic years when he was stable, productive, and successful as shown by his holding DOD security clearance and a demanding technical government job.

When he was active-duty in the Navy, he was AWOL for 2 days that he spent in jail for a fight in a Georgia bar. He was arrested in Seattle, WA, in 2004 for shooting the tires of another man’s vehicle in what Mr. Alexis later described to detectives as “an anger-fueled blackout.” However, it was more likely the event was during an episode of irritable mania. In 2010 he was investigated in Ft. Worth, TX, “for discharging a firearm [through his ceiling] after his upstairs neighbor said he [Alexis] had confronted her in the parking lot about making too much noise.” A friend in Ft. Worth said that Alexis went 3 days without sleep around that time. These behaviors suggest mania.

A month prior to his rampage (August 7, 2013), Alexis called the police in Rhode Island to complain that he had changed hotels three times because he was being pursued by Navy personnel, who were keeping him awake and harassing him “by sending vibrations through the walls with a microwave machine.” He researched, called, and told a D.C. area Electronic Surveillance and Mind Control Support Group that the Navy was “targeting his brain” with a new experimental weapon that transmitted Extremely Low Frequency (ELF) waves that caused him to hear “voices speaking to him through the wall, flooring and ceiling.” He believed the Navy ELF research was being conducted at the D.C. Navy Yard. There is a diagnostic grandiosity to these delusions and auditory hallucinations.

On August 23, Alexis went to the Veterans Affairs Hospital in Providence, RI, where he had been working as a contractor, complaining of insomnia. Alexis said he could not sleep, and doctors there prescribed him an antidepressant commonly prescribed for insomnia, Trazodone. Five days later, Alexis went to another Veterans Affairs Hospital in Washington, D.C., where he had traveled to work on another job at the Navy Yard. Alexis told medical personal in Washington that he was still having trouble sleeping and that the doctors prescribed him more Trazodone.29–32 Such hyperactivity of changing hotels three times during the course of a couple of days, calling the police, going to two hospitals, calling the Mind Control Support Group, his reported paranoid and grandiose delusions, insomnia, past episodes of violence, and his murderous rampage interspersed with times of competent functionality are consistent with mania rather than schizophrenia (Table 1).

Dylan A. Quick, on the Lone Star Community College Campus; Cypress, near Houston, TX; April 9, 2013

At about 11:15 a.m. on April 9, 2013, Dylan Andrew Quick, a 20-year-old part-time student at Lone Star College, attacked “at random” at least 14 of his peers with an X-ACTO blade during a psychotic state. He focused his blade on his victims’ faces; no one died. He was described by his lawyer as “an earnest young man who texted his mother frequently, read voraciously with friends at book clubs, and worked at his college library.” This suggests a baseline of euthymia and the absence of psychosis; however, Quick had substantial mental health issues. Reminiscent of the grandiose delusions of Holmes involving Batman (discussed next), Quick became grandiose and fascinated with the character, Hannibal Lecter, from the movie “The Silence of the Lambs.” A Hannibal Lecter mask was found at his home, and Quick admitted that he had fantasized for years about “cutting off people’s faces and wearing them as masks,” as Dr. Lecter had in a movie when he killed and sliced off a guard’s face and wore it as a mask to escape prison. In January 2011, Quick texted his parents threatening suicide. After his arrest, he was sent for evaluation by mental health officials, but results have not been published.33–36 His activity during the attack is similar to the frantic activity of Loughner in Tucson, AZ, and his delusional system revolving around Dr. Lecter is grandiose, bizarre, and consistent with psychotic mania. Details about his sleep, speech, activities, thoughts, and other manic behaviors in the hours and days before his rampage would be required for more confident diagnostic considerations.

James E. Holmes, at a movie theatre; Aurora, CO; July 20, 2012

While dressed as the Batman comics’ character, “The Joker” and wearing a protective vest, James Eagan Holmes, 24 years old, murdered 12 and injured 58 individuals in an Aurora, CO, theater during the Friday midnight premier of a new Batman movie. Both before and after his rampage he made grandiose, disorganized, incomprehensible, and delusional statements to a number of people, including the owner of a gun club he tried to join. About 3 weeks prior to the rampage, the gun club owner said that, “Mr. Holmes’ voice mail, in hindsight, sounded like the Joker … it was like somebody [Mr. Holmes] was trying to be as weird as possible.” Consistent with a psychotic killer, after his assault, Holmes seemed to wait by his car for the police to arrest him.28

Holmes is the son of a registered nurse and a mathematician working as a senior scientist. His father has degrees from Stanford, UCLA, and Berkeley. In high school, Holmes played soccer and ran cross country. Beginning in 2006, Holmes attended the University of California, Riverside and, in 2010, received his undergraduate degree in neuroscience with the highest honors. He was invited to join Phi Beta Kappa and Golden Key. He graduated with a 3.949 GPA in the top 1% of his class. In 2011, he enrolled in a doctoral program in neuroscience at the University of Colorado, Medical Campus, in Aurora. In 2012, his academic performance declined, and he dropped out of his studies in early June 2012. His apartment was decorated with Batman paraphernalia. Holmes was seen by at least three mental health professionals at the University of Colorado prior to the massacre and was diagnosed with schizophrenia. Some of his peers suspected that he suffered from mental illness and could be dangerous.28

His hyperactivity included the purchase at least four firearms, more than 6,000 rounds of ammunition, a black urban assault vest, and a knife in the 2 months prior to his rampage. He had also dyed his hair red.28

According to media reports, Holmes has been diagnosed with schizophrenia, but based on the plans, activities, calls, purchases, timing, and premorbid successes — specifically outstanding performance at a high academic level — followed by psychotic grandiose delusions, anger, and violence, psychotic mania is a diagnostic consideration (Table 1).

Anders B. Breivik, in Downtown Oslo and on Utoeya Island; Norway; July 22, 2011

While wearing a fake police uniform, Anders Behring Breivik, 32 years of age, executed his carefully considered grandiose and politically motivated plans. He blew up a government building in downtown Oslo before driving to another site on Utoeya Island, where the Labour Party Youth Camp was being held. There he killed a total of 77 people, mostly teenagers and young adults. Breivik stated his motive, saying that the attacks were “necessary to stop the ‘Islamisation’ of Norway.” Breivik referred to himself as “the future Regent of Norway, Master of Life and Death … and ‘Europe’s most Perfect Knight since World War II.’” Previously, he had distributed electronically “a [massive] compendium of [bizarre] texts entitled: ‘2083: A European Declaration of Independence’” demonstrating a grandiose, paranoid, psychotic, politically based delusional system. In 1997, while employed as an investment banker at the age of 18, he lost the equivalent of $369,556 in the stock market. He was educated and held a demanding professional position but also had suffered past states of depression, withdrawal, and isolation, according to media reports.38 Despite this, Breivik was subsequently diagnosed with schizophrenia. Premorbid success followed by episodes of depression and politically based psychotic, paranoid, and grandiose delusions in a violent psychotic mass killer are compatible with psychotic mania (Table 1). Others have opined that Breivik is a sane terrorist.39

Jared Loughner; at a political rally, Tucson, AZ; January 8, 2011

Jared Loughner, 22 years old, shot 19 people (including then-Congress member Gabrielle Giffords) at a political rally in Tucson, AZ. Six died, including a 9-year-old girl. According to media reports, on the night before his rampage, Loughner may have gotten little or no sleep. Media research indicated that he posted incoherent writings on MySpace in the middle of the night. At 7:04 a.m., he drove to buy more ammunition and was stopped by law enforcement for running a red light; however, he was not detained. Back at home, a heated argument with his father prevented him from driving the family car to his rampage; instead, he took a cab. His father described his behavior during these days as being out of control. At the site of the massacre, his behavior was described in the media as follows: “Mr. Loughner kept up his fatal barrage, dancing up and down excitedly, turning from Ms. Giffords before firing, apparently indiscriminately, at her constituents, staff and the random passers-by.” He did not try to flee and was taken down by survivors as he tried to reload to kill more people. Insomnia, hyperactivity, politically motivated grandiosity, and violence by a rampage killer indicates psychotic mania, as did his past and family histories40–44 (Table 1).

During the years before the rampage, his high school and college teachers described a pattern of inappropriate, disruptive behavior during classes “marked by hysterical laughter, bizarre non sequiturs, and aggressive outbursts.” Episodically both in high school and at Pima Community College, police were summoned when Loughner disrupted the classroom. At least one classmate, who sat by the door when Loughner attended the class, and one of his instructors said they were fearful of him.40–44 Loughner instilled fear in others, as did Cho, Alexis, and Holmes (Table 1). He had a family history of bipolar disorder; yet after his arrest, two medical evaluations concurred in the diagnosis of paranoid schizophrenia. During treatment in prison, Loughner admitted he had “harbored a grudge against Ms. Giffords for years.” He is now serving seven consecutive life sentences.45,46

Seung-Hui Cho, in classrooms on campus at Virginia Tech; Blacksburg, VA; April 16, 2007

Around 7:15 a.m., Seung-Hui Cho, 23, killed two students in their dormitory rooms. He may not have slept at all the previous night. Cho returned to his room to re-arm himself and mailed an extensive package to NBC News. At approximately 9:45 a.m., Cho then crossed the campus to Norris Hall, a classroom building where, in a span of 9 minutes, he shot dozens of people, mostly students, killing 30. As police breached the area of the building, Cho committed suicide with a gunshot to his temple. Cho had left a note in his dormitory that contained a rant referencing Christianity, in which he stated, “Thanks to you, I died like Jesus Christ, to inspire generations of weak and defenseless people.”47

Prior to the rampage at Virginia Tech, some of Cho’s professors and fellow students found him “menacing” and became concerned for their own safety. On a previous occasion, Cho told another student during a telephone call that he was in North Carolina vacationing with Vladimir Putin, the President of Russia. He sent another message with the words, “I might as well kill myself now.” Alerted by campus authorities, the police escorted Cho to the Virginia Mental Health Agency serving Blacksburg. He was diagnosed with schizophrenia and major depressive disorder. Outpatient treatment was recommended, but apparently neither Cho nor the Mental Health Agency followed up.33

The package Cho mailed to NBC News in New York was diagnostic of mania when considered with his actions noted above. It contained 25 minutes of video; 43 photographs; 23 pages of bizarre, disorganized written material; and 23 PDF files that were last modified at 7:24 a.m. after the first two murders. In his writings sent to NBC, Cho included threatening messages to then-U.S. President George W. Bush, Vice President Dick Cheney, and Secretary of State Condoleezza Rice. An autopsy revealed the absence of any drugs or alcohol.47 Note that the activities of Carey, Alexis, Quick, Holmes, Breivik, Loughner, and Cho included making and executing detailed plans, inducing of fear in their teachers and classmates (especially Holmes, Loughner, and Cho), and having psychotic grandiose and politically flavored delusions that together suggest mania and a diagnosis of severe bipolar I with psychotic features, rather than schizophrenia (or, in addition for Cho, a major depressive disorder) (Table 1).

Discussion

Diagnoses of schizophrenia noted in this presentation are based upon media research of medical records. Speculations of mania by the author are also based on media reports when they contained adequately detailed and diagnostically meaningful descriptions of the killers’ behaviors. There were no personal interviews by this author.

As would be expected, there are many behaviors common to the seven cases that suggest mania and a diagnosis of a bipolar disorder (Table 1). All initiated lethal, psychotic rampage behaviors that required increased and extensive activities in making and carrying out plans, often over months to years and sometimes in a frantic state, but usually executed quite calmly. All seven of these rampages were motivated by psychotic delusions characterized by grandiosity and paranoia that was often politically based (Carey, Alexis, Breivik, Loughner, and Cho). Insomnia was indicated in four cases (Holmes, Loughner, Cho, and Alexis), and excessive writing reported in three (Cho, Loughner, and Alexis). All had experienced pre-rampage episodes of modest if not exceptional success and past episodes of manic behaviors. At least five gave warnings and at least four instilled fear in their peers. A positive family history of bipolar was recorded in only the case of Loughner. There were no reports of negative family histories for bipolar disorder in any of the other perpetrators. At least four had had contact with mental health professionals prior to their rampages, and all seven were diagnosed with schizophrenia either before or after the rampage.

Psychotic manic patients misdiagnosed with schizophrenia do not receive standard of care since they are given lengthy, if not lifetime, prescriptions of antipsychotic drugs with significant adverse side effects, but are not given first-line mood-stabilizing medications.48–50 The case of Alexis is even more egregious since his chief complaint at two different Veterans Affairs Hospitals was insomnia, a common complaint, but also a cardinal sign of mania. A few additional observations and questions might have confirmed that he was manic, dangerous, and homicidal. Giving an antidepressant to a manic patient is generally thought to be contraindicated.51–53 His script for the antidepressant, Trazodone, on two occasions could have worsened his mania, as now recognized in DSM-V by naming bipolar type III for antidepressant-stimulated manic symptoms.9,51–53 Cho was also diagnosed with major depressive disorder and schizophrenia, and similarly could have been prescribed contraindicated antidepressants.

There is precedent for the legal profession to change the diagnostic habits of psychiatrists. In the 1990s, some psychotherapists inappropriately encouraged some of their adult female patients to overendorse the “recovery of repressed [false] memories” of early childhood sexual abuse, usually attributed to a male family member. These misdiagnoses destroyed many families until lawsuits against the therapists by wrongly accused fathers and uncles helped slow the recovery of such false memories. Successful legal action in the form of a class action lawsuit filed on behalf of unrecognized bipolar patients misdiagnosed with and mistreated for schizophrenia could quickly change psychiatric diagnostic practices. Another potential class action suit is possible from some of the mass murder victims’ families in cases where, before the rampage, the psychotic manic murderer had been treated for schizophrenia and not for a bipolar disorder.

Conclusion

Friends, families, caretakers, counselors, and physicians of patients with psychotic mood disorders, as well as the public at-large, are at risk for violence and murder, especially when they are un-or misdiagnosed and go untreated.54 Some advocate for mental health to be deemed a public safety issue and for easier commitment laws.4,25 Efforts toward enforced medication compliance seem necessary.24

The disease-specific diagnostic criteria of mania, such as delusional grandiosity, must dictate a diagnosis of a bipolar disorder in psychotic patients. A broad interpretation of and focused attention to grandiosity is fundamental to accurate diagnostics in psychotic patients. When mental health attention is received prior to a rampage, more effective treatments and better outcomes can be expected if a diagnosis of a bipolar disorder rather than schizophrenia is considered in psychotic individuals.

Ultimately, mental health professionals may abandon obsolete diagnostic concepts that promote substandard medical care for psychotic patients. With correct diagnosis and treatment, psychotic bipolar patients have a real chance to improve and suffer less frequently from the severe psychotic episodes that can lead to violence, suicide, homicide, and, rarely, even mass murder.

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Summary of Manic Symptoms in Lethal Rampage Perpetrators

Case # Single, Caucasian Male Pre-Rampage Contact w/Mental Health Insomnia Suicide / Suicide by Cop (SbC) Increased / Frantic Activities Excessive Writing (EW) Political/Bizarre Grandiosity Diagnosis of Schizophrenia Paranoia Past History of Violence/Mania Warnings Times of Successful Employment / School Instilled Fear Prior to Rampage Family History of Bipolar
1 Carey Answer unknown Carey (?SbC) Carey Carey Carey (also PPD) Carey Carey Carey Carey (maybe at work) Answer unknown
2 Alexis Alexis Alexis Alexis Alexis Alexis Alexis Alexis Alexis Alexis Answer unknown
3 Quick Answer unknown Answer unknown Quick (threatened) Quick Quick Quick Quick Quick Quick Quick Answer unknown
4 Holmes Answer unknown Holmes Holmes (arrested) Holmes Holmes Holmes Holmes Holmes Holmes Holmes Answer unknown
5 Breivik Answer unknown Answer unknown Breivik (arrested) Breivik (+ writings) Breivik Breivik Breivik Breivik (planned for years) Breivik Breivik Answer unknown
6 Loughner Loughner Loughner Loughner (arrested) Loughner (+ writings) Loughner Loughner Loughner Loughner Loughner Loughner Loughner
7 Cho Cho Answer unknown Cho Cho (+ writings) Cho Cho (also MDD) Cho Cho Cho Cho Answer unknown
Authors

C. Ray Lake, MD, PhD, is Professor Emeritus, Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine.

Address correspondence to: C. Ray Lake, MD, PhD, Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, Kansas City, KS 66160-7341; email: craylake@hotmail.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20140502-06

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