Psychiatric Annals

Guest Editorial Free

Mental Health Aspects of Mass Violence

Britta K. Ostermeyer, MD, MBA

Mass violence creates a huge impact on a given community often for many years, if not a lifetime. Because there is no universal definition for mass violence, many different definitions are used.1 The term “mass murder” refers to a “multiple homicide event in which four or more victims are murdered within one event and in one or more locations in close geographical proximity.”1 The resource center for victims by the National Center for Victims of Crime reports that mass violence “can generally be defined as an intentional violent criminal act that results in physical, emotional, or psychological injury to a large number of people.”2 Such acts can take many forms, with the most common way manifested through mass shootings.2 Other ways that people can inflict mass violence include terrorist bombs, mass riots, aircraft/transportation hijackings, or bioterrorism attacks.2

Although mass violence events are deeply troubling, they remain rare occurrences.3,4 Mass shootings accounted for less than two-tenths of 1% of all homicides in the United States between 2000 and 2016.4 People are much more likely to kill themselves intentionally with a gun than to be killed by a gun in a mass shooting or other type of homicide.4 Mass violence/shootings remain unpredictable, especially by persons outside the perpetrator's social circle, due to their extremely low base rate.3 There is little research to guide mental health professionals and law enforcement to better identify such perpetrators ahead of time.3 Because many perpetrators leak information about their grandiose plans to family members and acquaintances, such persons should be educated to notify authorities and be provided with information on existing help and resources.3

Incidences of senseless mass violence are terrifying and traumatic, and communities demand explanations.4 Unfortunately, in the wake of those events, mental illness is often blamed and deemed responsible as a major contributor to these tragedies. Simplistic conclusions tend to ignore the multifactorial aspects and complex interplay of psychopathology (especially narcissism), emotional turmoil, social stressors, cultural issues, as well as traumatic events that play a role.3,4 Most people who commit mass murders do not have a major psychiatric disorder. However, they commonly have feelings of anger and revenge, are extremely disgruntled, experience social alienation, exhibit paranoid traits, often have been bullied or otherwise traumatized in childhood, and are preoccupied with grandiose fantasies of revenge against their perceived tormentors.3 They rarely seek mental health services, but rather typically perpetuate their horrific acts outside the awareness of mental health professionals.3 Most of these perpetrators admit to having been enticed by previous mass killers, who received significant media attention, and they narcissistically, almost desperately, crave such “antihero” media fame as well.4 Therefore, it is of utmost importance for the media to deny them their longed for fame and “rewards” by not disclosing any identifying information.

Of important note, most people with mental illness typically are not dangerous toward others.3–7 The overall rate of violence against others committed by people with mental illness is approximately 3% to 5%,5–7 and an even smaller percentage use firearms for violent acts.3 In general, there is a low correlation between mental illness and violence in the absence of substance abuse.3,8 Therefore, laws intended to reduce overall gun violence that focus on the low incidence of people with mental illness who are violent will prove ineffective.3 In fact, increased attention should be paid to sociocultural factors associated with mass killings.3

This issue of Psychiatric Annals presents articles on mass violence in a clinically relevant manner for mental health clinicians. The first article, “School Shootings Revisited for Clinicians,” by Dr. Eleanor Lastrapes and colleagues revisits clinically pertinent information on school shooters. The second article, “The Role of Mental Health in the Aftermath of Terrorism,” by Dr. Ashley H. VanDercar and colleagues provides an important oversight on mental health issues after terrorism. The third article, “Risk and Resilience in Children in the Context of Mass Trauma,” by Grace L. Whaley and colleagues discusses trauma risk and resilience in children in the aftermath of mass trauma. The final article, “The Influence of Media Related to Mass Shootings,” by Dr. Praveen R. Kambam and colleagues informs clinicians about the potential role that media may play in influencing perpetrators and future incidents.


  1. National Mass Violence Victimization Resource Center. About mass violence. Accessed August 10, 2020.
  2. National Center for Victims of Crime. US Department of Justice. Victim Connect Resource Center. Mass violence. Accessed August 10, 2020.
  3. Knoll JL, Annas GD. Mass shootings and mental Illness. In Gold LH, Simon RI, eds. Gun Violence and Mental Illness. American Psychiatric Association Publishing; 2016:81–104.
  4. National Council for Behavioral Health. Mass violence in America. Causes, impacts and solutions. Accessed August 10, 2020.
  5. Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry. 2006;163(8):1397–1403. doi:10.1176/ajp.2006.163.8.1397 [CrossRef]
  6. Appelbaum PS. Violent acts and being the target of violence among people with mental illness—the data and their limits. JAMA Psychiatry. 2020;77(4):345–346. doi:10.1001/jamapsychiatry.2019.4266 [CrossRef]
  7. Appelbaum PS, Swanson JW. Law & psychiatry: gun laws and mental illness: how sensible are the current restrictions?Psychiatr Serv. 2010;61(7):652–654. doi:10.1176/ps.2010.61.7.652. [CrossRef]
  8. Martone CA, Mulvey EP, Yang S, et al. Psychiatric characteristics of homicide defenders. Am J Psychiatry. 2013;170(9):994–1002. doi:10.1176/appi.ajp.2013.12060858 [CrossRef]
Britta K. Ostermeyer, MD, MBA

Britta K. Ostermeyer, MD, MBA, is a Practicing Board-Certified Forensic Psychiatrist; the Paul and Ruth Jonas Chair in Mental Health; a Professor and the Chairman, Department of Psychiatry and Behavioral Sciences, University of Oklahoma College of Medicine; and the Chief of Psychiatry for OU Medicine and the Mental Health Authority of the Oklahoma County Detention Center, University of Oklahoma Health Sciences Center.

Address correspondence to Britta K. Ostermeyer, MD, MBA, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, P.O. Box 26901, WP3470, Oklahoma City, OK 73126-0901; email:

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


Sign up to receive

Journal E-contents