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Violence and Mental Illness: Not a Direct Link

Do we know the risk factors of mass murder?

There have been 22 US incidents of mass murder since 2000 (Larry Cohen, 8/1/2012, Huffington Post). A multi-victim shooting is underway in Wisconsin as I write this.  Some of the alleged shooters of the last decade with multiple victims are dead and some have not been tried. Let me be clear that I believe that everyone in this country is innocent until proven guilty. However, we need to find answers to preventing the increasing number of mass murders in the last decade. This article, while speculative, given those that have not yet been tried, looks at the similarities among 6 suspected mass murderers.

Is being mentally ill a risk factor for violence? The McArthur study found that hospitalized severely mentally ill people were less likely to be violent that those in the general community. Additionally, the study found that being dually diagnosed with a mental illness and a substance abuse disorder placed a person at greater risk for violence that those without a dual diagnosis. A NIMH Epidemiological study found that people with mental illness (16% lifetime prevalence) are slightly more likely to be violent than the average person in the community without a mental illness (7% lifetime prevalence). However, those with both severe mental illness and substance abuse disorders were 7 times more likely to be violent than those without either disorder.

From my research I would add several proposed risk factors for young adult male violence. These factors are backed by research. I propose that the more factors a person has, the more likely the person is to become violent. Knowing the risk factors can help professionals provide effective treatment for those that come to their attention. The factors include: belief in aggression as a means to an end, problems at school or at work, difficulty getting along with others, anger management problems, violent communications, and major life stressors which injure self-esteem. This article researches what is publicly available about some of these factors and 6 known or alleged mass murderers: Timothy McVeigh (found guilty of 1995 Oklahoma City Federal Building bombing, killed 168, wounded 800), Seng Hui Cho (Virginia Tech shootings, allegedly killed 32 and wounded 17, deceased), Jared Lee Loughner (alleged Gabriel Giffords shooting, killing 6 and wounding 14, not yet tried, involunntarily medicated, reportedly considering a guilty plea deal), Nidal Hassan (Fort Hood shooting, 2009, where 13 were killed and nearly 30 wounded, not yet tried), Anders Breivik (alleged Norway shooting and bombing, where 77 were killed, evaluation for not guilty by reason by insanity), and James Holmes (alleged Colorado Theater murderer, 2012, where 12 were killed and 58 were wounded, not yet tried).

Four of the six, Seng Hui Cho, Jared Lee Loughner, Anders Breivik and James Holmes have been previously diagnosed as mentally ill. Of the remaining 2, Timothy McVeigh was ex-military and Nidal Hasan was active military. Both believed they were carrying out a war of sorts against the US government. They may eventually be classified as “lone wolf terroists.” Whether or not they had a diagnosis of a personality disorder is unknown. Breivik and Loughner likely had a dual diagnosis that included mental illness and substance abuse.

Although, in general, the first psychotic break may happen when a person with a mental illness is in his late teens or early 20’s, there are often signs of a mental illness before the first break with reality. The media reported that Seng Hui Cho was suspected of some kind of mental health problem since childhood. No evidence that it was treated is apparent at this time. Reportedly, Jared Lee Loughner acted strangely since high school according to a friend of Loughner’s, Bryce Tierney, and was told to leave his college campus and not return until he had a mental health evaluation. No one followed up to see that the evaluation took place. Loughner was declared incompetent to stand trial, diagnosed with Schizophrenia and was medicated against his will. There are now reports that he may plead guilty on Tuesday. On 8 June 2012, Professor of Psychiatry Ulrik Fredrik Malt testified in court that Anders Breivik was diagnosed with Asperger syndrome, Tourette syndrome, narcissistic personality disorder and possibly paranoid psychosis. It is unlikely that no one noticed he was severely mentally ill and dangerous before he slaughtered 77 people in Norway in July of 2011. If others noticed that he was mentally ill, treatment might have been helpful to stabilize him. The media reports that James Holmes was seeing a psychiatrist 6 weeks before the shootings and she alerted the Risk Assessment Team at the college. Those known to have undergone or been recommended for a mental health assessment and treatment before their attacks occurred are Seng Hui Cho, Jared Lee Loughner, and James Holmes. The reduction of community mental health funding and lack of focus on prevention over the last few years may have contributed to some people not getting the help they needed early in their illness.

Social Problems and Awkwardness

All 6 of the persons in this article reportedly were socially awkward or had interpersonal difficulties. Seng Hui Cho and James Holmes reportedly had difficulties in relationships to others. McVeigh was bullied in school. His nick name was “Noodle McVeigh” according to the book, American Terrorist. McVeigh’s and Beivik’s peers included extremists that advocated hatred of other groups of people. Jared Lee Loughner, reportedly, had an exaggerated sense of his own importance and disdained other people that he thought were not as smart or important as he was, according to an interview with his friend, Bryce Tierney, in Mother Jones. He eventually stopped hanging out with his few friends and reportedly slept a lot, using “lucid dreaming.” Nidal Hasan was reported to have difficulties with others, especially when proselytizing a radical form of the Islamic faith.

School and Job Difficulties

It appears that all six of the alleged examples used here had school or job difficulties of a significant nature. Timothy McVeigh entered a 2 year business college, but dropped out and had a series of odd jobs ( He did very well In the Army, but dropped out of the intensive Special Forces Program and then the Army. He then bought and sold guns all over the country. The events at Ruby Ridge and Waco, Texas reportedly fueled his hatred of the government. He had no empathy for his victims and called the death of children in the bombing “a PR nightmare.” Nidal Hasan, allegedly, had job difficulties resulting in poor work evaluations. Seng Hui Cho had difficulties in his college classes. Jared Lee Laughner was asked to leave college. James Holmes had been successful in school, but allegedly failed an exam before he attacked people in the Colorado theater. Anders Breivik allegedly was rejected by the military and was bankrupt at one time.

Purchase of a large arsenal

All 6 had a strong interest in or purchased a large quantity of guns or bomb making materials. While purchased legally, the very large amounts could be a red flag that something needed investigation. Timothy McVeigh spent part of his young adult life after his military career, buying and selling guns at gun shows and he later purchased a large amount of fertilizer for his bomb. Anders Breivik purchased guns legally. He also purchased a farm and 6 tons of fertilizer which he mixed with fuel, reminiscent of McVeigh’s bomb. Holmes reportedly bought a large number of guns and a huge amount of ammunition legally. Nidal Hassan was a gun enthusiast and was very knowledgeable about and had a great interested in guns.

Violent Communications

Four of these suspects had violent communications. Holmes is suspected of writing a violent communication to his psychiatrist and it is unknown if Loughner produced any violent communications. It is alleged that Seng Hui Cho wrote about violence in his college classes. Timothy McVeigh studied the Turner diaries, written by former American Nazi Party official William Pierce, which is full of violent racist and anti-Semitic fantasies. It became the blueprint for revenge and he often referred to the book and introduced other people to it ( Anders Breivik’s manifesto contained sections of Ted Kaczynski’s manifesto and supported anti-Muslim and violent ideas. Nidal Hassan openly expressed his violent, extremist ideas to others.

Major Life Stressors with Attacks to the Ego

All of these men had major life stressors that could have produced blows to the ego or reduced self-esteem. Seng Hui Cho experienced stress in his classes. He was mostly non-verbal, but was allegedly pressured to be verbal in one of his classes. Timothy McVeigh could not find steady work after leaving the military. He also dropped out of the military after failing Special Forces training. Jared Lee Laughner reportedly was asked to leave college and not return until he had a mental health evaluation. James Holmes allegedly was not performing well and withdrew from college after having an excellent academic record. Hasan allegedly had been given poor evaluations by supervisors and had been assigned to be deployed to a war zone. He was very much against his deployment. Breivik attempted to enlist in the military but allegedly was found “unfit for duty” and at 18, he lost 2 million kr on the stock market (Wikipedia).

The media has reported that all of the 6 men described here had interpersonal problems and school and job difficulties, purchased a large arsenal of or had strong interest in weapons, and experienced recent major life stressors that likely were blows to the ego. Four had violent communications with others. Only 4 of the 6 have been described as being mentally ill and only 2 are reported to be substance abusers. If only this data were used, the conclusion might be that if a young man in his 20’s has severe interpersonal problems, job/school difficulties, a major life stressor with a blow to the ego, is purchasing or has strong interest in weapons, and appears to be mentally ill and a substance abuser, that person would need to be evaluated for dangerousness and encouraged to engage in treatment. The formula would need to be tested, but taking a risk management perspective, it might be better for family members, employers, and schools to reach out to men with these characteristics with an array of services that could reduce their risk of engaging in a tragic event. It will be cost effective in the long run to do so.

In the interim, we need a dialogue in this country about 1) How do you determine whether someone is dangerous to self or others; 2) what to do when professionals or family members have concerns about a person's dangerousness 3) the effectiveness of the requirement that the danger be imminent in order to have someone committed to a forensic hospital for a thorough evaluation.


The pendulum has swung from keeping people in hospitals for the mentally ill too long to making it almost impossible to have someone committed to a hospital for 72 hours to determine if he or she is going to harm himself or other people. While most mentally ill people are not dangerous, some are and people do sometimes stop taking their medications and become dangerous and hurt other people. That has to be fixed while protecting individual rights. A balance must be found.


The other problem is that clinical judgment of future dangerousness is little better than chance and the research is very clear about that, but mental health professionals in the US continue to use clinical judgment to determine if someone is dangerous. There are valid and reliable tools to increase the accuracy of the determination of dangerousness and appropriate treatment plans, but they are not widely used in the US. A new conversation around this issue is also needed.


An additional issue is the continued emptying of hospitals for severely and chronically mentally ill persons (since 1968) and the reduction in funding for community mental health services in recent years. It is hoped that the Affordable Care Act with better integration of physical and mental health care will reduce the overall cost of healthcare and improve the provision of mental health services. More readily available and higher quality mental health and substance abuse services could help prevent future violence.

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–Dr. Kathy Seifert