This issue of Psychiatric Annals addresses a crisis both in the U.S. and around the world — that is, rampage mass murders by psychotic individuals who endanger, if not kill, between 1,000 and 2,000 innocent victims each year in the U.S. alone, including children. Mass murders are horrific tragedies that gain intense media coverage; they do not seem rare any more. Efforts at prevention must go beyond gun control and focus on understanding more about the perpetrators. This is a challenge and has relied primarily on reviews of media, medical professionals, police, and legal reports. When available, the communications of the perpetrators and interviews with them have been valuable. Because the diagnoses of the perpetrators are controversial, the lead editorial argues to justify an exception to the Goldwater Rule when discussions of the diagnoses of psychotic mass killers can aid in prevention. The three full articles in this issue have in common the goal of advancing efforts at prevention.
The areas of expertise of the contributors are strikingly broad, ranging from a psychoanalytically informed approach to forensic psycholinguistic analysis of the communications of psychotic mass murderers, all the way to simple clinical differential diagnostic analysis of the perpetrators.
James L. Knoll, IV, MD, and J. Reid Meloy, PhD, ABPP, are internationally recognized for their research on mass murderers. They make a substantial contribution with the third paper in this issue, “Mass Murder and the Violent Paranoid Spectrum.” They assert that there are about 20 such cases each year in the United States. They acknowledge that, “mass murder is a multi-determined event with no simple preventative solution. Such tragedies are exceptionally hard to anticipate and avert.” In their contribution, utilizing forensic psycholinguistic analyses, they probe a complex set of motivations that suggest common themes of social persecution, envy, and especially retribution and revenge, which are often the central motives for mass murderers. The authors address “… a theatrical aspect to [the killers’] vengeance, which requires witnessing …” by an audience in addition to a target for revenge. The killers thus provide for an audience various communications, written, videotaped, or posted on the internet that the authors thus study as “… rich sources of data providing a deeper understanding of a perpetrator’s motive, mental state, and psychological disturbances.”
This represents an important potential method of prevention by enabling “… a more informed clinical risk assessment and management that examines … availability of means, planning, preparation, and the acknowledged commitment to put the words into action irrespective of consequences.” They hesitate to “… draw conclusions beyond the hypothesis that [mass murder] is caused by a ‘complex interaction’ between psychopathology, traumatic life events, and precipitating factors.”
The first full article in this issue, “Rampage Murderers, Part I: Psychotic Versus Non-Psychotic and a Role for Psychiatry in Prevention,” distinguishes psychotic from non-psychotic mass murderers in hopes of identifying common characteristics of potential mass murderers. Twenty-three cases are analyzed. The primary motive of 15 was psychotic delusions, four were terrorist-motivated, and in four, anger and revenge were motives. There were also overlapping motives in some. About half of psychotic rampage killers have contact with mental health professionals before their rampage, giving us an opportunity to improve recognition and prevention.
The second full contribution is titled, “Psychotic Rampage Murderers, Part II: Psychotic Mania, not Schizophrenia.” 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, suggest states of psychotic mania, defining a bipolar disorder, not schizophrenia. Critical to a correct diagnosis is the recognition that delusional grandiosity, often tinged with a political flavor, is diagnostic of mania but is usually obscured by paranoia. Paranoia has been associated with paranoid schizophrenia but derives from the delusional grandiosity of mania. Similarly, the delusional guilt of psychotic depression leads to flagrant paranoia that hides the core guilt (and the depression). The century-old Kraepelinian Dichotomy that schizophrenia and psychotic mood disorders are different has been discounted. Primary psychoses are explained by psychotic mood disorders, mania, and depression.
Since the standard-of-care treatments for schizophrenia and a psychotic mood disorder differ, a correct diagnosis is critical for the most effective care and for maximum efforts at prevention of psychotic rampage murders. Successful class action litigation can change psychiatric diagnostics faster than a revised Diagnostic and Statistical Manual.