Psychiatric Annals

Guest Editorial Free

This issue: Justification for Breaking the Goldwater Rule: Mass Murderers’ Diagnoses

C. Ray Lake, MD, PhD

On May 23, 2011, Richard Friedman, MD, published a piece in The New York Times discussing the history of the Goldwater Rule.1 He said, “Just before the 1964 [Presidential] election, a muckraking magazine called Fact decided to survey members of the APA [American Psychiatric Association] for their professional assessment of Senator Barry Goldwater of Arizona, the Republican nominee [running] against President Lyndon B. Johnson.” Of the 12,356 members who were sent the highly unscientific survey, 2,417 members responded. The assessments were “brutal.” Terms used referring to Mr. Goldwater included “… megalomaniac, paranoid, and grossly psychotic … schizophrenia.”

In 1973, the APA defined a set of requirements for communicating with the media that became known as the Goldwater Rule. The rule is Section 7.3 of the APA’s ethics principles and states:

“On occasion, psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”2

Dr. Friedman discussed clear transgressions with regard to psychiatrists diagnosing Domonique Strauss-Kahn, who had just been arrested in 2011 on sexual assault charges in New York City. Dr. Friedman also addressed exceptional circumstances when the importance of the diagnosis of an individual “… rise[s] to the level of a national threat …” that might warrant an exception to the Goldwater Rule.

On September 16, 2013, a psychotic and likely manic Aaron Alexis, 34, a contract employee for the Department of Defense with security clearance, randomly shot and killed 12 innocent people at the Washington, D.C. Navy Yard. About 2 weeks afterward, at least three prominent psychiatrists discussed his diagnosis in the public media and concurred that Alexis suffered from schizophrenia. In his National Review piece on September 19, 2013, Charles Krauthammer, MD, said in reference to Alexis that his, “delusions, paranoid ideation, auditory (and somatic) hallucinations: [are] the classic symptoms of schizophrenia.”3 Jeffrey Lieberman, MD, a recent President of the APA and current Chairman of Psychiatry at Columbia University, School of Medicine, 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” regarding Alexis’ Navy Yard massacre.4 Dr. Torrey said, “about half of these mass killings are being done by people with severe mental illness, mostly schizophrenia.” Drs. Lieberman and Torrey are quite right 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. At issue is the correct diagnosis for such psychotic mass killers.

The three articles that comprise this issue of Psychiatric Annals address motivations involved in lethal rampages, including the diagnoses of the perpetrators. Since the treatment differs between a bipolar disorder and schizophrenia, and approximately half of the psychotic mass murderers had seen a mental health professional before their rampages, debate in the public forum about diagnoses of psychotic rampage killers is warranted, in this author’s opinion, because such discussions are likely to contribute to efforts at prevention.


  1. Friedman RA. How a telescopic lens muddles psychiatric insights. The New York Times. May22, 2011.
  2. Goldwater Rule. Wikipedia. Available at:
  3. Krauthammer C. The real Navy yard scandal. The Washington Post. WP Opinions. Published on September 19, 2013.
  4. Kroft S. Untreated mental illness an imminent danger? [transcript]. 60 Minutes. September29, 2013.


About the Guest Editor

C. Ray Lake, MD, PhD, is Professor Emeritus of Psychiatry, The University of Kansas School of Medicine, Kansas City, KS.

Dr. Lake graduated from Tulane University in 1965. He received an MS in Insect Physiology, also from Tulane, in 1966. He graduated from Duke University, School of Medicine, and Duke Graduate School (Department of Physiology and Pharmacology), in Durham, NC, in 1971 and 1972. He studied at Oxford University and at St. Bartholomew’s Hospital, London. His residency in psychiatry was completed at Duke and at the National Institute of Mental Health (NIMH). He remained at the NIMH Laboratory of Clinical Sciences as a Research Associate and Staff Psychiatrist until 1979, when he moved across the pike to take a professorship of Psychiatry and Pharmacology at the new Uniformed Services University of the Health Sciences (USUHS) School of Medicine. He secured two RO1 research project grants to continue his research on the regulation of the sympathetic nervous system in health and in patients with neuropsychiatric and/or cardiovascular disorders.

In 1993, Dr. Lake accepted the Chairmanship of Psychiatry at the University of Kansas School of Medicine and remained chair for 3 years, after which he continued on the full-time faculty until his recent partial retirement. As Professor Emeritus, he continues to publish, teach students and residents about mood disorders, and follow his long-term patients. He has more than 250 publications and has achieved life-fellowship status in the American Psychiatric Association and the American College of Neuropsychopharmacology. His current interests are the misdiagnosis of schizophrenia and a more effective strategy for teaching medical students about psychiatry. His book, Schizophrenia is a Misdiagnosis, was published by Springer in 2012.


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