Robert Gallon, PhD – Brain Blogger Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 An Ecological Model for Dysfunction Wed, 20 Jul 2016 15:00:51 +0000 In previous essays, I’ve discussed a way to look at mental disorders, not as discrete medical entities, but as attempts to describe types or patterns of psychosocial problems. I’ve called these dysfunctions that can be placed on dimensions of dysfunction. Dimensions have no breaks between normal and abnormal, between sane and mentally ill; only more or less.

Now, it is time to address the factors in human experience that either cause dysfunction or protect us from it. For convenience, we can clump these factors into the biological, the psychological and the social. Because these factors interact in complex ways, I like to call it an ecological model. This model contrasts with the typical psychiatric one in which mental disorders are seen as either medical diseases or psychogenic.

The model I’m talking about was first introduced by George Engel in 1977 and was called the biopsychosocial model. Engel wrote that psychiatry was in crisis because “adherence to a model of disease is no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry.” He recognized that conceiving mental disorders as bodily aberrations “leaves no room within its framework for social, psychological and behavioral dimensions of the illness.”

Given my background in biological psychology, it was only natural that I gravitated to Engel’s model when I joined the Psychosomatic Medicine Clinic at Thomas Jefferson University Medical School. In 1978, I organized a multidisciplinary symposium on psychosomatic medicine which featured some of the major contributors to the biopsychosocial model and resulted in my book The Psychosomatic Approach to Illness in 1982. This approach has been the foundation for the dimensional model I’m presenting here.

The ecological metaphor is apt for this approach because what we conceive of as mental disorders are adaptations to an individual’s biopsychosocial environment. We are all doing the best we can to thrive – and sometimes just survive – in the complex and particular world in which we live. We each have individual talents, attributes and preferences and learn different ways of coping with life stressors. We then have to live in a social world where must meet demands and rules to achieve our goals and desires. Mental disorders do not strike us down like polio or cancer, but are deficiencies in our adaptive capacities. Below, I’ll outline some of the biological, psychological and social factors that make up this ecology.

Biological factors

We are all born human. None of us is born a lobster (I live in Maine) or a baboon. So all of our attributes are within the range of the human genome. We each come into this world with our own particular assortment of abilities and propensities, emotions and temperaments, and peculiarities. Some of these peculiarities may be related to genetic anomalies, but known ones are rare and there are no clear connections between them and the characteristics that mark different mental disorders. Further, the more we learn about epigenetics, the more we recognize that whether certain genes are expressed or not depends on environmental conditions. What we are left with is that to call a mental disorder genetic is an essentially meaningless statement.

This brings us to the concept of heredity. Heredity is a statistical statement, not a genetic one. It tells us the odds of some attribute being associated with genetic factors, but not the mechanism. For instance, studies show that in identical twins (who share the same genes), if one twin is described as schizophrenic, the other twin has a 48% chance of being described that way by the same criteria. What happens to the other half? Something other than genes are at work here.

The best way to understand data of this sort is in terms of susceptibility. Some unknown thing makes a person genetically vulnerable to the kind of cognitive disruption that is labeled schizophrenia, for instance. More generally, due to our individual biology, we are likely to have different degrees of susceptibility for impairments in functioning across different areas. We can’t say more than that.

More profitably, we can examine brain functioning for clues to a biological substrate for human behavior. The architecture of the human brain follows a consistent plan, but within that plan we each have an individual brain, just as we have unique faces and bodies. The brain we inherit or one that is altered by injury, illness or life’s experiences is the foundation of our behavior. But, like a sculptor’s medium, the marble or the clay, the brain sets limits and direction, but does not directly determine the work of art that results.

A striking fact about the human brain is that we are born with far more neural connections than we actually need. In the course of brain development, experience prunes away unneeded connections. The Nobel laureate Gerald Edelman termed this process “neural Darwinism”. Additionally, groups of neurons that activate together form closer bonds. As Edelman put it, “Neurons that fire together, wire together.” The current concept of brain development is more like an ecosystem then a machine. Each neural network is in constant competition with other brain components throughout our lives. The upshot of this is that a brain’s susceptibility to different forms of dysfunction is an exceedingly complex process. Sorting out specific brain factors may provide important clues, but it will never be determinant for mental disorders.

Psychological factors

What we should be clear about is that for us human beings, especially compared to all other animals, brains are shaped by life’s experiences. From the moment we enter the world, we begin to adapt and learn in order to meet the demands of the world around us. As we mature, these demands become more complex and social. We continuously develop our behavioral repertory, based on our abilities and needs. At each stage of life, we must develop new coping mechanisms to meet new challenges.

The patterns of behavior, thinking and feeling that we develop are what we call our personalities. Each personality has its strengths and weaknesses as the person confronts life. Some personality characteristics successfully help us lead satisfying lives, but others may be maladaptive and lead to chronic dysfunction. For instance, some maladaptive personality patterns may leave is unable to form rewarding interpersonal relationships. Other personality attributes leave us vulnerable to anxiety or depression.

Biological susceptibility combined with maladaptive personality resources can make us vulnerable to sudden breakdown. Most people are resilient. They have acquired adequate coping skills to create a firm sense of self and can recover quickly from stressors or conflict. It is likely, though, that each of us can break down if the stress is too great or too prolonged. People who suffer losses may become depressed and people who are threatened by events they cannot control may become anxious. Even otherwise well-functioning people may lose their grip on reality and become psychotic if the threat to self is too intense. On the other hand, some personalities are rigid and subject to catastrophic breakdown, called decompensation. Severe dysfunction of this kind may be labeled schizophrenia, major depression or panic disorder.

Another element of personality is the power of our beliefs. The way we learn to think about ourselves and the world about us influences the way we behave and feel. Maladaptive thinking and false assumptions are a major source of dysfunction. Analysis of the ideas people form about themselves, how they interpret the consequences of their actions and the relationship these thoughts have to distress have been the focus of a remarkable group of psychological thinkers collectively called cognitive behavioral theorists. They have formulated the techniques of cognitive behavior therapy, which teaches the skills necessary to cope effectively.

Social factors

The power of situational forces to influence our actions, feelings and even our beliefs is vastly underestimated. We have a strong bias toward attributing psychological problems to dispositional factors; that is, personal qualities. When we look for causes of other people’s behavior, we invoke genetic make-up or personality or mental illness. But we are social animals, programmed by evolution to respond to and be shaped by the social forces around us.

The social context is of equal importance to personal attributes, such as mental disorder, in any attempt to understand the level of dysfunction a person exhibits. This context includes the rewards, punishments, social norms and expectations a person is subject to at any given time. These factors can be protective when they boost an individual’s self-esteem and can lead to the belief that the person can overcome difficulties. They can also be destructive and increase dysfunction when they reinforce disability.

My experiences with such social factors has given me additional reason to be extremely skeptical of mental disorder diagnosis. I have often found multiple clinicians making diagnostic pronouncements without the least regard for their patients’ life circumstances. They seem to be so focused on fitting a person’s complaints to the diagnostic criteria for mental disorders and coming up with a label that they pay no attention to the facts of a person’s life even when they know them. They do their patients no service when they don’t step back and take an objective look at the context of their patients’ lives. Clinicians need to learn as much as they can about those circumstances and be modest and circumspect in assigning labels.

Image via geralt / Pixabay.

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Dimensions of Madness Mon, 18 Jul 2016 15:00:51 +0000 In my previous essay, I characterized mental disorders as descriptive types that can be placed on dimensions of dysfunction. I called the result a dimensional typology. Now, I’ll discuss what I mean by this.

The dimensions are the important things because they describe the broad categories of mental health problems that people can have and estimate just how seriously those problems impair an individual’s ability to function in life. In my view, mental disorder characterizations are merely linguistic placeholders on each dimension that describe observed patterns of dysfunction. They should reflect the relative severity of the dysfunction. Mental disorders are not discrete entities and have no definite boundaries. They are part of the continuum that make up the dimension.

There are no discontinuities in any of these dimensions. There are no lines separating normal from abnormal, well from sick or sane from insane. Dimensions simply range from extremely well-functioning to extremely impaired. We all function at some level on each of these dimensions.

DSM-5 appears to have come part way to this approach by describing some mental disorders as spectra. There is a schizophrenia spectrum and an autism spectrum and the DSM authors could have described a bipolar spectrum and others as well. But a spectrum is not a dimension because it still implies abnormality. People have to be diagnosed with a mental disorder in order to appear on the spectrum and everybody else is presumed to not be on it.

Where people fit on any dimension of dysfunction is not a static thing. All of us probably exhibit some degree of emotional, cognitive or behavioral dysfunction at some times in our lives. Most of us, though, lead lives on the more functional end of each dimension at least most of the time. Those of us who exhibit more extreme dysfunction on some dimension are the ones who get labeled schizophrenic, autistic, intellectually impaired or bipolar and the like. But they are only different from the rest of us in degree, not kind.

To better understand the dimensional model, I’ll offer the following imaginary illustration. Suppose we had an instrument, perhaps like an intelligence test, that could measure the attributes that characterize each dimension. The results of such an instrument would summarize the component dysfunctions and put them on a scale.

In my imaginary scale, each dimension would probably have a shape something like a normal or bell-shaped curve. Each would range from extremely good functioning to extremely poor with no breaks in these curves. We could, though, characterize different regions of each dimension, just as we do with IQ. The largest percentage of us would demonstrate adequate functioning with some people above average and some below. People in this average range might exhibit some degree of dysfunction or symptoms at least some of the time, but they can be expected to cope reasonably well.

A small percentage of people might be term super-functioners on a particular dimension and they would be unlikely to ever experience any of the deficits marking that sort of dysfunction. Below the average range, we could describe a smaller percentage of people who we might term borderline dysfunctional. These people display chronic deficits or significant vulnerabilities in the relevant dimension. As we get below borderline, the percentages get smaller and smaller as they describe people with a greater degree of impairment and perhaps times of severe disability. A very small percentage of people at the lowest end would exhibit a profound level of dysfunction.

There are dramatic cases of people on several of these dimensions who might be unable to function outside of institutions such as hospitals or prisons or otherwise be unable to perform everyday tasks or responsibilities. Among these are the people we typically call mentally ill.

The dimensions

Surveying the current descriptions of mental disorders and my own experience, I settled on nine primary dimensions of dysfunction. If other professionals accept a dimensional approach, they might conclude that there are more or less than nine dimensions and I might find that reasonable. We might also choose to define several sub-dimensions within each one. I would welcome a thorough discussion of these issues. Here, I will briefly describe each dimension as I see it and I will discuss each in detail in later essays.

  • Reality misperception: Schizophrenia is the poster-child for this dimension and is usually defined as a break with reality. The ability to distinguish external or consensual reality from internal imaginings and thoughts is central to good functioning. People with deficits in reality testing have a very difficult time dealing with the social world we must live in. Mental disorders like schizoaffective and delusional disorder fit on this dimension.
  • Depression and mood dysfunction: Mood dysregulation is a prime source of dysfunction. We are by nature moody in that our emotional states vary over time and circumstance. Most of us, though, are relatively stable and capable of going about our daily lives without significant emotional disruption. Those of us whose moods are extreme or protracted exhibit mood dysfunction. Terms like depression, mania and bipolar disorder describe the more dysfunctional end of this dimension.
  • Anxiety and its consequences: Anxiety is related to fear and fear is an essential survival mechanism. Some degree of anxiety is necessary for good social functioning. But when anxiety or its consequences becomes disproportionate, it is increasingly dysfunctional. Generalized anxiety, panic and phobias describe dysfunctional expressions of anxiety. Other disorders that are presumed to be anxiety -related, such as posttraumatic stress disorder, dissociative phenomena and obsessive-compulsive disorder fit on this dimension.
  • Cognitive competence: IQ is a term currently out of favor, but it is obviously true that intelligence highly correlates with good functioning in many areas of life. Intelligence has long been considered dimensional and is described by a normal curve, so it serves as a model for all my dimensions. Most people have adequate enough cognitive competence to live functional lives, but a small percentage do not. We now describe such people as having an intellectual disability or an intellectual developmental disorder. In company with intellectual disability, I include the form of cognitive deterioration called dementia, which we may acquire later in life.
  • Social competence: We are intensely social creatures and living independent and functional lives requires an adequate degree of social competence. Social competence requires an ability to read other people’s emotions, intentions and reactions. This ability goes by the term Theory of Mind. Social competence also entails control of our social behavior so that it is appropriately responsive to social settings. Both the autistic and attention deficit/hyperactivity disorders fit on this dimension.
  • Pain and bodily illness: Our sense of well-being and ability to cope with life is strongly influenced by our perception of somatic symptoms and our concerns about them. Paying attention to our bodies makes good survival sense. But in this age of modern medicine, many people develop dysfunctional beliefs and attitudes in response to perceived bodily ills. Chronic pain is a prime example when it overwhelms a person’s life. Other disorders that fit on this dimension are hypochondriasis, somatization and conversion disorders.
  • Substance misuse and dependence: We are told we have an epidemic of drug abuse and there certainly are many tragic stories associated with drugs. But this ‘crisis’ is 100-year war with no solutions insight. We must rethink what problematic drug use really means and how dysfunctional addiction really is. To do that we must stop making moral distinctions between good drugs that we see as medicines, evil drugs that we buy on the street and the ugly drugs we buy in retail stores. We must also define drug addiction, drug dependence and drug abuse in a new way. This dimension describes the dysfunctional use of all psychoactive drugs.
  • Controlling impulses and desires: Humans have needs, emotions, impulses and desires that we must appropriately express. Some expressions of what I’ll call drives and emotions are particularly destructive to social interactions and others are more directly harmful to the individual. The less able we are to appropriately regulate and direct our drives, the more dysfunctional we become. There are many motivations that can become dysfunctional, but I highlight sexuality, anger, hoarding, Internet addiction and greed.
  • Socialization dysfunction: A well-functioning society requires people who behave socially. This dimension is not about social competence because it is about how we treat others. Socialization deficits lie in caring for others, empathy and concerns about other people’s rights. At the low end of this dimension are society’s most destructive people we describe as psychopaths – people who lack conscience or concern for anyone outside themselves. Moving up the dimension toward the functional end, I describe abusers and bullies. Then in the less dysfunctional region are the types of people who take advantage of people who get close to them. I call these people tar-babies. People in the mild end of dysfunction are what I describe as unhappy loners who either lack the social skills for intimate relationships or who alienate others.

As a model for describing psychological dysfunction, I naturally direct my attention to deficits that significantly impact people’s lives. I can’t tell you what percentage of the population that dysfunction encompasses because “it depends”. What it depends on is appraising the factors that are going into creating dysfunction. I call the combination of causal factors that can contribute to dysfunction an ecological model consisting of biological, psychological and social factors. I’ll discuss this next time.

Image via eak_kkk / Pixabay.

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A New Look at Mental Disorders Thu, 14 Jul 2016 15:00:06 +0000 Although I’ve written a long book focused on mental disorders, I don’t really believe in them. At least, I don’t believe that mental disorders are quasi-diseases that cause people’s problems and that doctors can diagnose. Nor are mental disorders discrete biological abnormalities like chemical imbalances that can be cured by the right medications.

The language of medicine is misleading. There are no true diseases in psychiatry. In the history of medicine, whenever an objective biological cause is found for some mental impairment, it leaves the realm of psychiatry and becomes part of neurology or internal medicine.

In the past, what we now recognize as stroke, seizure, dementia and many other brain diseases were seen as psychiatric conditions. Few would call them that now. Schizophrenia, bipolar disorder and anxiety remain mental disorders precisely because they are not diseases. I have no doubt, though, that in the future there will be new diseases identified that will come to describe various brain conditions now seen as psychiatric.

A little history

The first psychiatrist to attempt a formal classification system for madness was Emil Kraepelin who, incidentally, was born in 1856, the same year as Sigmund Freud. In the late 1800s, the mental asylums were filled to the bursting with seemingly permanent patients. Kraepelin was a psychiatrist of the asylum where the poor and the undesirable were confined as well as a professor at Heidelberg University. His life’s work was to classify mental disorders as “disease entities” in a manner that emulated the “hard” medical sciences of neurology and pathology.

What he did was to distill the case studies of thousands of hospitalized patients into core signs of mental illness and chart each patient’s course over many years. He had his residents fill out an index card on each patient and put the card in a ‘diagnosis box’. Kraepelin had a platform for his work because he had published a Textbook of Psychiatry and he announced his initial conclusions in the fourth edition of 1893.

As he reshuffled his index cards, Kraepelin concluded that there were only two major forms of mental disease and one minor one. The one with the poorest outcome he called Dementia Praecox, a term he based on his colleague Alois Alzheimer’s studies of senile dementia. In Kraepelin’s view, Dementia Praecox was an irreversible mental deterioration beginning at a young age. He had a very negative view of these patients who he described as “symptom carriers”. He described their symptoms using terms such as “atrophy of emotions” and “vitiation shun of the will”.

His second major mental disease he called circular insanity, which encompassed all types of mood disturbance. These patients had some hope of recovery and could be treated. Having only two types of insanity certainly simplified diagnosis and decision-making. Dementia praecox was incurable, so the asylum’s role was to warehouse these patients and no treatment was offered.

In the early 20th century, Kraepelin’s diagnostic labels would be changed to schizophrenia and manic depressive illness. Kraepelin’s ideas about a biological cause for mental disturbance was gradually supplanted by Freud’s psychogenic explanations, but his influence lived on through the early decades of the century.

They had a large influence on the Eugenics Movement of the 1920s and 1930s, which viewed the insane as carrying defective ‘germplasm’. In the US, the Eugenics Record Office kept track of the burden such misfits placed on society and one advisory panel recommended that 10% of the population should be sterilized.

Kraepelin’s name seemed lost to history after the Nazi atrocities were exposed after World War II, but his ideas went underground. He was resurrected in the late 1960s by a group of psychiatrists who wanted to adopt a completely biological approach to mental disorders. In 1972, psychiatrist Gerald Klerman christened this attitude neo-Kraepelinian. In 1978, he published what has been termed the Psychiatric Manifesto with these edicts:

  • “Psychiatry is a branch of medicine.”
  • “Psychiatry treats people who are sick and who require treatment for mental illness.”
  • “There are discrete mental illnesses.”
  • “The focus of psychiatric physicians should be particularly on the biological aspects of mental illness.”
  • “There should be an explicit and intentional concern with diagnoses and classification.”
  • There was resistance from the Freudians, but for many psychiatrists this was just what they were looking for. They could now practice real medicine in company with other physicians. They also had the financial and public relations support of the increasingly powerful pharmaceutical industry. These companies marketed their ‘revolutionary’ psychiatric drugs as antipsychotics, antidepressants, mood stabilizers and anxiolytics. These drugs were described as specifically designed to treat distinct psychiatric diseases.

    In 1980, the neo-Kraepelinians beat back the Freudians to produce a new version of the Psychiatric Diagnostic and Statistical Manual of Mental Disorders. DSM-III was very different to its predecessors. It was 500 pages long and contained a great many more diagnoses. Reactions and other Freudian terminology were eliminated. Above all, it was considered to be much more empirical and objective with specific rules as to the kind and number of symptoms needed to diagnose a given disorder.

    Present day psychiatry

    Up to the present day, the neo-Kraepelinian approach to diagnosing mental disorders is almost universally accepted by the mental health professions and the public alike. We act like mental disorders are just like diabetes and heart disease, but this does not hold up.

    The first problem is that there are no objective markers for any mental disorder despite psychiatry’s incessant attempts to find them. DSM-IV conceded as much when its editors wrote:

    “It must be admitted that no definition adequately specifies precise boundaries for the concept of mental disorder.”

    The diagnosis of a mental disorder remains a matter of observation, inference and opinion, not medical fact. The percentage of people in each diagnostic category is totally dependent on consensus opinion and not physical tests.

    There are no provable biological mechanisms underlying any class of mental disorder despite the years of trying. At the beginning of the psychiatric drug era, the prevalent theory was that since these drugs affected specific transmitter systems in the brain, there must be chemical imbalances in those systems. But there is no credible evidence that there are such any shortages were over-supplies of transmitter substances in the brains of people diagnosed with mental disorders. Has psychiatrist Peter Breggin succinctly put it, “Psychiatric drugs don’t correct biochemical imbalances – they cause them.”

    It is worth noting that DSM-5 (the most recent edition), finesses the whole medical issue. It does not speak of diseases, but instead calls a mental disorder, “a syndrome characterized by clinically significant disturbance.”

    At the time it was being developed, psychiatrist Donald Luchins admitted that despite “extensive study of brain chemistry no mental disease has ever been established.” He went on to say, “no doubt mental or psychiatric illnesses involve the brain. But the term brain disease is already used to describe neurological illness.” In other words, there are no brain diseases in psychiatry. Psychiatric diseases are metaphorical and metaphorical diseases are not true diseases.

    Mental disorders as types

    There are advantages in using the term mental disorder to characterize different patterns of human dysfunction. Classifying people this way provides a non-moralistic and (hopefully) non-pejorative way to describe people’s problems in a manner (again, hopefully) that is acceptable to them.

    Mental disorder labels have a long history and generally represent a consensus of a large number of experts and the collective wisdom they bring to the table. Also, mental disorder diagnoses play a prominent and perhaps necessary role in many social institutions. I do argue, though, that the current diagnostic system could be vastly improved if it was de-medicalized.

    So what is the alternative to a biomedical system of classification? Mental disorders are human-constructed descriptive types, not scientific categories. Technically, scientific classification systems are called taxonomies, while a system based on subjective description and expert opinion is called a typology. The distinction is analogous to the one between the Periodic Table of Elements and the Dewey Decimal System. The Dewey Decimal System classifies books by their contents in the opinion of library experts. No scientific theory predicts which book will receive which number. A valid mental disorder system would seek to classify human psychological problems in a similar manner.

    In my view, the classification of mental disorders should be seen as a dimensional typology. This means that we try to group people’s problems into patterns and then locate these types on a limited number of dimensions. I have attempted to do this by describing these types as falling on dimensions of dysfunction. These types do not have discrete boundaries and there is no separation between the normal and the abnormal. Each dimension ranges from very good functioning to very poor. I will discuss the dimensional idea in detail in my next essay.

    Meanwhile, I will end with an opinion. I find the term mental illness to be particularly offensive, no matter how well-meaning its use. It is a meaningless and insulting label for a powerless minority group. Like ethnic and religious slurs, it is a term imposed on people, not one they would choose for themselves. It serves only to distinguish us ordinary people who are presumably sane, from those inferior people whose minds are diseased.

    We reassure ourselves that we would never think or act the way those people do. Whenever I hear someone talking about erasing the stigma of mental illness, I cringe. If we want to eliminate stigma, then stop calling people names.

    Image via brenkee / Pixabay.

    ]]> 0 On Mass Murderers Wed, 11 May 2016 15:00:40 +0000 We observe the modern epidemic of mass murder in this country and are shocked. We can’t understand who these (mostly young) men are who take the lives of innocents for no apparent reason. What could possibly drive them to do it?

    Seeking reassurance, we search for what makes these murderers different from us. In the wake of yet another horrific mass shooting, we must reassess our understanding of the underlying cause.

    We conclude that these killers are mentally ill. Legislators devise laws to prevent people who have been committed to psychiatric hospitals or otherwise judged mentally ill from owning guns. Mental health experts demand more psychiatric services to identify and treat them. Even Dear Abby writes, “The triggers that have led to the plague of mass shootings in this country are the result of individuals with severe psychosis (Bangor Daily News, 11/23/ 2015).” It is satisfying to us to believe that we can identify mentally deranged people who commit these crimes, and that they are not like us.

    In Europe and much of the rest of the world, there is another group of slaughterers called Islamic Jihadists. When the recent events in Paris unfolded, the world watched horrified as a small cell of ISIS terrorists indiscriminately gunned down scores of random people. We see this as a political-religious act by radicalized Islamists, not a product of mental illness. But how much difference is there, really, between American mass murderers and foreign jihadist ones?

    A recent article in The New Yorker by Malcolm Gladwell (“Thresholds of Violence,” 2015) analyzed the genesis of school shooters in the US. Over the past 20 years, there has been a long series of cases following a similar pattern. One or two young men go into unprotected schools and randomly start shooting unarmed students and teachers. Gladwell points out that since 2012, there have been 140 school shootings in America. Some of these young men, such as Kip Kinkel, had bizarre paranoid fantasies and can be identified as psychotic, but some such as Eric Harris of Columbine fame were more appropriately described as psychopaths. Some came from chaotic and violent homes, but others were loved by their families and un-traumatized. Then there was Adam Lanza. What are we to make of him?

    In December, 2012, 19-year-old Adam Lanza shot his mother, then went to Sandy Hook Elementary School where he murdered 20 children and six adults.

    Much of what is known about his early life was reported by Adam’s father Peter to Andrew Solomon of The New Yorker. Peter described Adam as exhibiting odd behaviors such as sensory hypersensitivity and social dysfunction from an early age. At age 13, a psychiatrist diagnosed Adam with Asperger’s syndrome and recommended he be home-schooled. In his high school years, he became increasingly isolated and distant from his parents. The only emotion he displayed to them was distress in connection with having to socially engage. Perhaps distracted by the Asperger’s diagnosis and unable to penetrate Adam’s secrecy, neither his parents nor mental health professionals were alert for signs of impending violence.

    From the clues he left behind, Adams emotions alternated from anger to despair. Anger may have been the only social emotion he was capable of comprehending. His anger was reflected in his increasing fascination with mass murder, which he expressed only online. In his late teens, he spent much of his time editing entries on mass murderers on Wikipedia. He was aware that he was failing in life and had no future. As Solomon put it, “The more Adam hated himself, the more he hated everyone else.”

    It seems reasonable to speculate that his final act was to take the life of his mother, whom he blamed for his problems, and then the lives of children who had the promise he could never realize. If we are to look for causes of Adam’s murderous behavior, they do not lie in Asperger’s or mental illness. It seems clear enough that the key to Adam and the common element behind mass murders is rage.

    For the Jihadist, the rage is religious and political. The non-believer is evil and an enemy. He must be destroyed or enslaved. The reward for killing the other is a place in heaven. For a mass murderer like Adam, the rage is interpersonal. It is against an enemy who is, in some way, oppressing or preventing the killer from getting what he deserves. The reward is achievement and fame. In either case, compassion has no place.  

    Gladwell’s formulation emphasizes the under-appreciated power of situational or social factors in determining our behavior. He invokes a theory of social thresholds. Each of us has a certain threshold for engaging in various actions, be they violent or benevolent. Take, for instance, a riot. One person in a mob of people who has a very low threshold (perhaps due to a high level of anger) throws the first rock followed by someone with a slightly higher threshold. A social contagion may then set in where individuals who would not have considered rioting get caught up and become participants. If there is sufficient social reinforcement, some people become mass murderers.

    One of the most famous social psychology experiments, Zimbardo’s Stanford Prison Experiment in 1971, showed the power of social influence and unchecked authority to turn ordinary people into malevolent prison guards or victimized prisoners. Zimbardo assembled a random group of seemingly normal young men and arbitrarily assigned them to the roles of guards or prisoners. Then, in an elaborate piece of theater, he created an isolated prison environment in which the men were told to follow the rules Zimbardo created. The astounding result was that both groups did not just play-act, but actually became the roles they were simulating. As Zimbardo described it, “the power that the guards assumed each time they donned their military-style uniforms was matched by the powerlessness the prisoners felt when wearing their wrinkled smocks with ID numbers sewn on their fronts.”

    Although they stopped short of actual physical abuse, the guards behaved cruelly and with little regard for their prisoner-peers’ humanity. Even the kindly doctor Zimbardo assumed the role of prison supervisor. He was blind to the abusive behavior his social experiment had created until his future wife confronted him from an outsider’s perspective.

    What Zimbardo showed was that under the right social circumstances, individuals with generally high thresholds for violent action can become Nazi Gestapo or Abu Ghraib prison guards. Unfortunately, this is the dark side of human social evolution that we have seen played out throughout history. There is nothing unusual in the phenomenon of one group of humans defining outsiders as others who do not warrant compassion or even respect.

    The commonality between mass murderers and Islamic Jihadists is that both groups have low thresholds for joining in on unspeakable violence. They then join or are influenced by a social group that glorifies violence. Jihadists operate in response to the social contagion of religious extremism which grows with each atrocity. School shooters and similar murderers are increasingly influenced by a virtual social group and a script laid out by their predecessors such as the Columbine killers. Adam’s social isolation and rage lowered his threshold for joining a virtual group for whom murdering innocents becomes a heroic act.

    We do not need to invoke mental illness. A personal sense of rage and social contagion is explanation enough.


    Gladwell, Malcolm, (Oct. 19, 2015). “Thresholds of violence: How school shootings catch on.” The New Yorker.

    Solomon, Andrew. (Mar. 17, 2014). “The reckoning: The father of the Sandy Hook killer searches for answers.” The New Yorker.

    Zimbardo, Philip. (2008). The Lucifer Effect: Understanding How Good People Turn Evil. Random House.

    Image via geralt / Pixabay.

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