Jamie Turndorf Ph.D.
We Can Work It Out
Was Adam Lanza an Undiagnosed Schizophrenic?
And could a proper diagnosis have averted the Newtown massacre?
Posted Dec 20, 2012
This past week, 20 children, none older than 7, and 6 adults were brutally slain by 20 year-old Adam Lanza in a Newtown Connecticut school shooting.
As the world continues to grieve over the Newtown massacre, we must strive to make sense of what transpired and decipher what we are all meant to learn from this tragedy that can improve our world.
This is the fourth mass shooting in this country this year. We've had 37 school shootings since Columbine. This is a big problem that is not going away.
Aside from the gun control issue, which has a lot of people fired-up, we are also looking at a failure of the mental health system and its prevalent modern diagnostic methods.
We also need to look at whether or not SSRI's or other therapeutic drugs were involved in this catastrophe (some drugs can possibly trigger violence in autistics), as well as examine various familial/educational/societal and cultural failures, including the stigmatization and alienation of the "mentally ill.”
Of course, the entire world is also wondering whether or not it is possible to recognize people in danger of doing this and how to help them.
Beyond all the aforementioned issues, could this event also be a lens that magnifies the violence that’s occurring on a worldwide scale, in the wars of religion and territory and even down to our most intimate relationships in which people act on impulse, shooting off verbal rounds at each other, including those we supposedly love rather than following the call to be more selfless and listen with the ears of our hearts to empathize and embrace others—even when we’re angry ourselves.
Let’s begin with an analysis of Adam.
Adam Lanza had been diagnosed with Asperger's, a mild form of autism often characterized by social awkwardness. People with the disorder are often highly intelligent. While they can become frustrated more easily, there is no evidence of a link between Asperger's and violent behavior.
It’s been reported that when people approached Adam in the hallways, he would press himself against the wall or walk in a different direction, clutching his black case, like an 8-year-old who refuses to give up his teddy bear.
Adam also underwent crises that required his mother to come to school to handle. Such episodes at times involved total withdrawal from whatever he was supposed to be doing in class, such as sitting and reading a book.
Adam had extreme difficulties relating to fellow students and teachers, as well as a strange bodily condition. One of his teachers said, "If that boy would've burned himself, he would not have known it or felt it physically." While he didn’t feel physical pain, he certainly must have been hurting emotionally. Was Adam’s rampage an attempt to make others know his emotional pain?
There’s more. Emerging research suggests that there are both clinical and biological links between autism and schizophrenia. Yet our current diagnostic hierarchy implies that the two conditions are distinct. The key take-away point is that there are some individuals who may have both autism and schizophrenia.
Adult psychiatrists and mental health professionals would benefit from further training in the diagnosis of autism (ASD) in adults, and child mental health professionals would benefit from training in the diagnosis of schizophrenia spectrum disorders in youths. According to research, given the complex symptom profile in youths with schizophrenia spectrum disorders, there tends to be a delay in diagnosis, even when symptoms are present for years. This delay could prove fatal! Why?
Decades of research has shown a correlation between schizophrenia and increased rates of antisocial behavior in general and violence in particular (Hodgins, 1992; Hodgins et al, 1996; Wallace et al, 1998; Angermeyer, 2000; Arsenault et al, 2000; Walsh et al, 2001). The evidence that such associations are not just statistically but clinically and socially significant is now overwhelming (Hodgins & Müller-Isberner, 2004). In addition, studies suggest that in prisons throughout the Western world 5–10% of those awaiting trial for murder will have a schizophrenic disorder.
Why, if the connection is so clear, has it not been widely recognized by clinicians and service planners? Equally puzzling is the question why have so many researchers and reviewers in the field either obfuscated or minimized the importance of the correlations to the point of irrelevance?
Interestingly, there is research showing that the link between schizophrenia and homicide may be mediated by substance abuse. In the study, "Schizophrenia and Violence: Systematic Review and Meta-Analysis by Schizophrenia," the authors conducted a systematic review of investigations that reported on risk of homicide in individuals with schizophrenia and other psychoses. Their findings were as follows: "Schizophrenia and other psychoses are associated with violence and violent offending, particularly homicide. However, most of the excess risk appears to be mediated by substance abuse comorbidity. The risk in these patients with comorbidity is similar to that for substance abuse without psychosis."
In other words, schizophrenics who are also drug addicts are far more likely to act out in violence. The failure to diagnose and treat someone who is a drug using schizophrenic leads to a greater risk of mass violence.
Clinicians also need to resist the prevalent tendency to pigeonhole patients according to their label or diagnosis. Once someone is placed in a diagnostic category, clinicians are often blind to the possibility that other conditions may exist. In the case of childhood autism, we need to be aware that there can be a dual diagnosis, meaning an autistic kid can also be schizophrenic. And, perhaps, some schizophrenic kids may be mislabled as autistic.
Adam clearly showed the unusual behaviors and mood-regulation difficulties that are characteristic of schizophrenia. Had a proper diagnosis been made earlier, and had proper treatment been instituted, might we have averted this tragedy? The bottom line is psychiatrists and other mental clinicians need to receive further training and education on this topic so kids like Adam don’t fall through the cracks.
In addition, there needs to be more vigilance on the part of the schools and their guidance counselors to be alert to problems within the student’s families: clearly this mother was in over her head with Adam. I also suspect that his mother may have been troubled herself.
Speaking of Adam’s mother. It has been reported that she owned 6 guns, including semi-automatic weapons with multiple high capacity magazines holding about 30 rounds each. When multiple assault weapons are kept at home, it raises the question as to whether the owner was riddled with paranoid and/or murderous urges of her own.
We also know that mom took her mentally disturbed son to the shooting range. While we don’t know what went on behind closed doors, we have to wonder if Adam was raised in a paranoid, rage-filled environment. Was he abused and/or taught violence? When a mother keeps six assault rifles in the same house as a child who is mentally ill, she is all but giving that child a license to kill. It doesn’t take a rocket scientist to realize that Adam was beyond enraged to have shot his mother in the face. Clearly, school officials need to be more vigilant and intervene in reporting families in need of assistance. In retrospect, one now sees that the writing was on the wall that Adam was destined to fall. The question is why nobody heard the call?
We also know that Adam was very different and very shy and didn't make an effort to interact with his classmates. The fact that Adam returned to his boyhood school and aimed his fire at those children's faces makes me suspect that he was also furious with the classmates of his youth. Was he bullied and humiliated because he had been unable to relate to other kids? This event is also a wake-up call to kids around the world reminding them of the need to be kinder to the mentally ill.
But there's more. We must beware of viewing this tragedy as simply a maniacal rampage of a chemically imbalanced, psychotic madman set adrift by our currently faulty diagnostic methods. In my view, this bloodbath magnifies what ails the world, the human race, every society and nation, and each of us as individuals.
We are all being destroyed by our mismanaged rage.
Adam’s violence is ultimately an extreme acting out of pent up rage. You don’t mortally wound other human beings, directing your fire at their faces, if you aren’t drowning in rage.
On a less extreme scale, most humans are struggling with their rage. We’re all guilty of acting out to a greater or lesser extent as we lash out and kill each other in various symbolic ways. In our relationships, we take shots at each other with our words. And sometimes we act out physically, and smash fists into walls or faces. And sometimes that rage spews out in gunfire.
All humans are born with two instincts: the life and the death instinct. The death instinct, or thanatos, is the source of aggression and hostility between people.
Rage is an instinctual reaction that arises whenever we feel threatened or endangered. If we allow our rage to be bottled up, it festers and places us in danger of blowing. I call this the ‘blivit.” 50 pounds of poop in a five-pound bag. Keep shoving more and more feelings into the bag and it will eventually break.
We also need to add impulse control to this mix. The stronger our impulse control skills are, the better we will be able to contain our rage and not act out. The weaker our skills, the shorter our fuses will be and the less time it takes before we blow.
Hence, a lot of bottled up rage and poor impulse control skills is the formula for disaster.
And when rage is turned away from the self, we see rage directed against others.
The rage that rages on a worldwide scale is ultimately the result of our collective failure to love each other properly. This failure exists at the level of the individual family and it bleeds outward from there to the entire world.
By the way, rage is never the primary emotion. When we become angry, it’s because we feel other more basic and vulnerable feelings such as hurt, sadness and fear.
I can only imagine how many times poor Adam felt hurt, sad and afraid. Who heard his pain? And how many years did his pain and anger fester and build until it morphed into the powder keg that exploded in gunfire.
Adam, in an odd way, can be seen as a messenger sent to alert all of us to the need to alter the way we handle our own angry feelings; to consider what we say before we speak, to ask ourselves how the other will feel before we say or do x, y or z. To consider whether what we intend to say or do will be helpful and constructive to the other person and our relationship or not? To remember that whatever you say or do boomerangs back on you. To work to cultivate the ability to be more patient, and to listen to those who are angry with us, and to help them to feel truly heard and understood, which in most cases resolves angry feelings.
As a final note, as we grieve perhaps we might also say a prayer of thanks to all the sacrificial lambs who died in this massacre. They, themselves, were also messengers chosen to give us all a serious wake-up call by putting this world’s failings in sharp relief.
ADDENDUM ADDED TO RESPOND TO JOHN ELDER ROBINSON'S COMMENTS ON MY ABOVE BLOG:
In your comment, you re-assert the official “party line,” which holds that autism and schizophrenia cannot exist in the same person.
Clearly, much research shows that these two conditions can coexist. The failure to recognize the fact that autisim can precede and/or co-exist with schizophrenia can be a dangerous mistake: while autistism is not linked with violence, schizophrenia can be, especially when a schizophrenic abuses drugs. Let me be clear: neither am I stating that all schizophrenics will become mass murderers.
In response to your point that, “Few people have touched upon the more likely reality - that Adam's condition or at least his potential for violence was known to either his parents and/or his clinicians but for whatever reason, he did not receive appropriate supports and treatment.” I am in total agreement with this statement, and what I am offering is a possible explanation, supported by research, why his family and especially health providers may not have recognized his potential for violence: because they, too, assumed that Adam was only autistic.
Here is a quote from an article in psychiatrictimes.com (http://www.psychiatrictimes.com/schizophrenia/content/article/10168/1822823) that summarizes the research upon which I have based my statements:
“Systematic studies of childhood onset schizophrenia COS show high rates of the disorder being either preceded by or comorbid with autistic spectrum disorders (ASD).7
A subset of children (28%) in the ongoing NIMH study of COS have been reported to have comorbid COS and ASD.7
A number of researchers use different terms to describe this complex mix of psychiatric comorbidity and developmental psychopathology. At the Yale Child Study Center, a subgroup of children with ASD was labeled as having multiplex developmental disorder.13,14 Researchers in the Netherlands used the term “multiple complex developmental disorders” (MCDD) to describe children who met criteria for ASD and also exhibited affect dysregulation and disordered thinking.15-18 Of significant interest are follow-up studies, which showed that psychosis developed by adulthood in 64% of children with MCDD.16
Although autism has long been recognized as a separate diagnostic entity from schizophrenia, both disorders share clinical features. Childhood-onset schizophrenia (COS), considered a rare and severe form of schizophrenia, frequently presents with premorbid developmental abnormalities. This prepsychotic developmental disorder includes deficits in communication, social relatedness, and motor development, similar to those seen in autism spectrum disorders (ASD).
Autism and schizophrenia may present as 2 separate disorders that need to be differentiated, or as comorbid conditions. It is important to remember that some individuals may have both COS and ASD, which has implications when designing appropriate biopsychosocial interventions. Adult psychiatrists may benefit from additional training in the diagnosis of ASD in adults, whereas child psychiatrists may benefit from increased comfort with identifying primary psychotic symptoms in autistic youth.”
I understand your wish to insure that gentle autistics are not stigmatized as violent psychopaths. However, it is clear that research overturns our previous notions and urges us to now accept the fact that some autistics can also suffer from schizophrenia. To face this reality simply because we don't wish to stigmatize those autistics who aren't schizophrenic may not only be dangerous, but we may be preventing many people from getting the proper support and treatment they need.
This article has also been released as a special edition of my Internet radio show: Click here to listen to this show or download the audio version on BlogTalkRadio.com.
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