To most of us, the mind of someone like
FOR THE RECORD:
Studies: In the "Patt Morrison Asks" Op-Ed column Wednesday, Dr. George Woods referenced a Framingham cardiological study of 350,000 patients as having taken place in England. The Framingham study is a long-running cardiological study in New England, begun in 1948 with 5,000 patients. —
There's intriguing research about young men's brains; how might Isla Vista fit into that?
We have always known that with the more serious psychotic illness, like schizophrenia and bipolar disorder, there is the "prodromal" [early] phase that starts somewhere in middle school and goes up to about [age] 25. I call it the "bubble, bubble, toil and trouble" phase, when the brain is developing. People with schizophrenia or severe bipolar — that's when their brains start to come apart. The story is, as we see with Mr. Rodger: young people who were doing well in elementary school but have this period of darkness. They become more isolated, more withdrawn. You see deterioration relative to functioning effectively, the onset of paranoia or psychosis.
Does ordinary teenage angst sometimes mask this?
Exactly. They start using drugs, acting out. [With] a psychotic disorder, what happens next is the crystallization phase, like [Gabrielle Giffords' shooter]
In some ways we are, but this is because of that prodromal phase. Loughner, the fellow in [Sandy Hook], the guy at
What did you think as you read Rodger's manifesto and watched the videos?
First, his description of this transition in his life, around 9 years of age, that got worse as time went by. That's [one of] the soft signs of schizophrenia and psychosis that one would look for. Second, the stilted language. A young guy using words like "jubilant" and "stature," yet academically he's not functioning that well. You find this stilted language in people along the spectrum of psychotic disorders. Third, his story about having a hard time learning how to skateboard. We often see [that] people who develop psychotic illnesses are awkward children.
His writing [shows that] his ability to perceive himself as other people saw him becomes increasingly impaired — seeing himself as isolated, this tremendous hatred of people. By the time we get to the videos, there's a facial expression you see with many people who are psychotic. It's called "flat affect," like they're dead behind the eyes.
If you could talk to one of the dead shooters, like Rodger or
I'd want to know the social history of the family — is there a vulnerability to mental illness? — just as you would with diabetes or hypertension. I'd want to know, what kept you from having the insight to say, "This is a problem for me, I need to get some help"? In most cases, that defines those who are so psychotic — they can't develop insight and are not able to look at themselves. The question I really ask is, "Without talking about the facts of the case, why are we here today"? This seems philosophical, but it is really a neurological question, [about] the ability to abstract, move out of oneself and see the bigger picture.
What kind of changes in law or public policy could accommodate what we know about such young men?
What we know has changed policy. The Supreme Court has taken young brains into consideration; they have said, you cannot execute adolescents, and they wrote eloquently about the difference in adolescent brains. [But] these [rulings] are based on the idea that developmental stages ended at 18 [rather than 25 or later]. We know better now.
The law and medicine are at such loggerheads. Medicine is about what's new and evolving; the law is about precedent. So it's a Catch-22.
How would you design a model to find and treat seriously ill and potentially dangerous people?
It would recognize mental illness without the tremendous stigma that we attach to it in this country in particular.
And we're not able to study mental illness the way we should because our approach to research is so different from other countries. Let me give you a cardiac example: In cardiology in the U.S., if you're able to get 5,000 people, that's a major study. But the Framingham study in England has 350,000 because it includes anybody in the national health system. Schizophrenia research, look at Finland. Mood disorder and brain research, England.
I'm not demeaning our research, but I am suggesting the way we have to develop our research puts us behind.
California has Laura's Law, which permits court-ordered outpatient mental care or medication, and a "5150" provision for involuntary commitment for 72 hours. Could they have helped in Isla Vista?
The 5150 law could have had some impact, but the problem is [the condition] has to be acute — suicidal or homicidal within a short time. You can't say, "My brother said this a week ago, I want you to take him in." And it's a Band-Aid, it's 72 hours, and [the possibility of] another two weeks. It doesn't speak to the long-term care we need.
Thinking less about violence than the tremendous numbers who are ill and aren't treated, Laura's Law in some ways is a better approach. But what if there's little [treatment] available? Laura's Law would be [most] useful if we had an intact comprehensive mental health system, but we're doing it backward.
Rodger's family seemed to do things right, getting him to therapists, spending money on his care, vigilant about him even as a young adult. Will some always slip through the cracks?
They were [trying]. If we were to develop comprehensive mental health systems, [we would] be able to catch many of these folks, but you're not going to be able to catch everybody.
And Rodger managed to fool the system.
He didn't have to do much to fool the system. We're so surprised the mentally ill can do anything that if they do just a couple of things that we would do, we suddenly assign them [qualities] that aren't true. He just told the police everything was fine and they didn't need to worry, and they went home.
Are some people overdiagnosed with mental illness and others undiagnosed?
We call people narcissistic, or this or that, but the question is, is it impairing your functioning? We're all a little narcissistic, we're all a little hysterical, we all may be a little bit obsessive. I couldn't have gotten through medical school without a certain quality of wanting to get things done — that's not mental illness. True mental illness impairs your academic, social, professional functioning.
What about the legal consequences for mentally ill defendants? You often hear laymen's anger at people "getting off" by reason of insanity.
That's so rare. The insanity plea is not a mental health conclusion, it's a legal conclusion. Mental health is the first piece of it. The law says either you don't understand or you don't appreciate right from wrong. If you don't think this person is a person, but an alien or demon, and you kill them, you're not guilty by reason of insanity. There are very few even incredibly psychotic people who fit into that category.
What actions would you like to come from Isla Vista?
One, I'd like to see pressure on
Two, access to lethality makes a difference. It isn't rocket science. It's a matter of changing our priorities and creating reasonable gun laws — not crazy gun laws where no one can have a gun but reasonable gun laws. And we need to train police and firefighters on what mental illness looks like.