Mental illness and mass shootings

Recently a well known psychiatrist, Dr. Gail Saltz, and Obama stated that most mass shooters aren't mentally ill. I'm a little perplexed about this since the most recent shooter, Chris Harper Mercer, and many others have at least a personality issues if not an actual personality disorder. A personality disorder is considered a mental disorder and according to Wikipedia mental illness and mental disorder are used interchangeably.

Most mass shooters are angry loners, not mentally ill. Mentally ill more likely to be victims #givestigmatheboot

According to Saltz they tend to be loners with anger issues. Seems fairly obvious but I'm guessing there is more. They tend to often have a preoccupation with becoming famous and getting some kind of revenge against an unfair world. This could indicate some issues with narcissism and antisocial behavior. Additionally, there seems to be some depression however not the clinical variety. All of these mass shooters know they will not survive so the act is essentially suicide.

One solution to this problem could be to somehow screen students using psychological tests such as the MMPI when they are matriculated into college. After that ones that showed a tendency towards that behavior could be monitored closely. I'm sure at this point psychologists have a profile of this type of person.Many would claim an invasion of privacy but so is getting shot at. The rights of the individual have to be balanced against the rights of the group. At the moment they are too much in favor of the individual.

According to DSM-IV, a mental disorder is a psychological syndrome or pattern, which occurs in an individual, and causes distress via a painful symptom or disability, or increases the risk of death, pain, or disability; however it excludes normal responses such as grief from loss of a loved one, and also excludes deviant behavior for political, religious, or societal reasons not arising from a dysfunction in the individual.^[

It's interesting, looking at this DSM-V definition of what a mental disorder/ mental illness is, how it has to cause distress to the individual. What about relatives and society? Perhaps if these mass shooters don't fit any definition the DSM-V needs to add a label just for them.

edit:

Here are a few articles I've read since writing this post that discuss the same topic. It appears one could profile these mass shooters but the description could apply to a lot of people. Mental health is part of the picture but not necessarily the most beneficial thing to focus on. A history of violence appears to be a better predictor.

What We Actually Know About the Connections Between mental Illness, Mass Shootings, and Gun Violence

Mass Murders Fit Profile, as Do Many Others who don't Fit Profile

How to Stop Violence

Manic depressive controversies

An interesting lecture from Nassir Ghaemi on the bipolar spectrum concept. According to him unipolar and bipolar used to both be encapsulated under the phrase "Manic Depression". "Manic Depression" meant someone who either experienced severe depression or mania. "Bipolar disorder" is defined by an individual having both depression and mania/hypomania. The two phrases differ only by a conjunction....something I hadn't paid attention to before. Additionally, according to Kraepelin, a well known historic authority on the topic, individuals displaying mixed states were more common than the ones who had more pure states of either depression or mania. This has been noted more recently by other researchers such as Benazzi who published a number of articles about people who experience mixed depression.

Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary

My experience with mixed depression

While my depression has been more chronic I have experienced periods of time when it lifted and I felt normal and productive. There has also been a pattern to some of these "remissions". They often occurred during my menses and when ever I altered my sleep schedule to a minor degree. These remissions weren't long enough by DSM standards to qualify for hypomania however as Ghaemi states, the threshold for hypomania is to a large degree arbitrary.

I have noticed as well that my depressions didn't seem pure. They often included good amounts of irritability, insomnia, racing/crowded thoughts, hypersexuality, and a little grandiosity. Somewhat interestingly these symptoms tended to occur in the late evening to the early morning hours. This has been noted by some researchers who study ultra rapid cycling in children. Many clinicians would probably categorize my experience as someone who is experiencing a pronounced diurnal variation but I am reluctant to think that since diurnal variation usually means a slight remission of symptoms throughout the day without hypomanic-like symptoms.

Manic-depressive insanity in the sense here delimited is a very frequent disease. About 10 to 15 per cent, of the admissions in our hospital belong to it. The causes of the. malady we must seek, as it appears, essentially in morbid predisposition.-- Kraepelin

Ghaemi's historical perspective different from DSM

Ghaemi's perspective much like Kraepelin is based on the big picture of evidence and history, not mainly on image. At the moment the DSM-V seems to be ruled by people who are primarily concerned with the public's image of them. They mainly don't want to appear like they are over prescribing and over pathologizing normal behavior. The fact that bipolar is no longer grouped with major depression under Mood disorders is one example of their over reaction to anti-psychiatry.

In conclusion Dsythymia not all that accurate

As someone who has experienced chronic depression with a moderate severity, I am tired of hearing how my so called Dysthymia is defined as mild and at one time in the past, a personality issue. Bipolar disorder has been generally viewed as more incapacitating and more endogenous while unipolar depression is more neurotic. Ghaemi and Kraepelin's theories make sense to me in light of my experience with depression. It has been for the most part, quite incapacitating, miserable and briefly quite pleasant.

The impact of a previous mental illness diagnosis on other health problems

A couple of weeks ago I went to the doctor due to some problems with my sciatic nerve and some other mysterious nerve sensitivity in my hands, face and feet. Googling my symptoms indicated the possibility of nerve damage which gave me some anxiety and I thought possibly there was some treatment for my sciatic problem. The doctor wasn't my regular one but another one since it was  a walk in clinic. I had initially intended to go to my regular doctor but she insisted that I go immediately to the clinic that day and that she didn't have any time to see me. My understanding was that my mysterious nerve symptoms overlapped with a description of  someone having a stroke so I indulged her anxiety and went in the clinic that same day.

Once I got there however they treated me like the neurotic one and the doctor insisted in the end that I should go to a psychiatrist despite the fact that I have no insurance coverage for mental disorders. For some reason the male doctor fixated on my irritated hands which were slightly red and dry(possibly due in part to the sun). Judging by his thinking he seemed to think I had OCD and or possibly Lupus. The Lupus could have been due to admission of some joint pain and my previous diagnosis of depression. His impression of my sciatic nerve problem was that it wasn't enough of a problem for him to treat it at all. I inquired about muscle relaxants (anti-anxiety meds) but he didn't want to prescribe for some reason. The philosophy of this clinic seems to be that anti-anxiety meds should be prescribed by a psychiatrist.

I have had a similar experience before like this. I mentioned some mysterious nervous symptoms and was referred to a psychiatrist. It seems like when a doctor can't find a suitable diagnosis they immediately try to label the person as unstable...not terribly logical but it apparently saves them from confronting their own ignorance. Admittedly, part of this problem could be due to an error in communication. Here is an excerpt from an article on the topic of mental health stigma.

From a public standpoint, stereotypes depicting people with mental illness as being dangerous, unpredictable, responsible for their illness, or generally incompetent can lead to active discrimination, such as excluding people with these conditions from employment and social or educational opportunities. In medical settings, negative stereotypes can make providers less likely to focus on the patient rather than the disease, endorse recovery as an outcome of care, or refer patients to needed consultations and follow-up services.

At this point, I still have problems with my sciatic nerve and can't walk for more than 15 minutes or so without resting due to the pain in my lower leg. Additionally, I have unusual sensitivity in my hands and feet which makes typing at the moment somewhat unpleasant. I am quite sure my previous diagnosis of psychotic depression is giving this doctor an excuse to not take my symptoms seriously and I am not sure what to do about it. Stigma due to mental illness is frustrating and it can impact other health problems which aren't taken seriously.

update: tests don't confirm Lupus

In defense of alternative medicine and Dr. Oz

Recently there has been a backlash against people like Dr. Oz who endorse alternative medicine. John Oliver was one person in particular who called Dr. Oz "the worst person in scrubs who has ever been on television". As someone with Dsythymia who has tried numerous medications and alternative treatments, I am annoyed at this because it kind of misses the big picture. If one considers the bigger picture one sees "science" endorsing antidepressants and a uncertain serotonin theory which has in turn stolen huge sums of money from people who have depression. For some reason when pharmaceutical companies deceive billions of people it is quietly goes unnoticed in comparison.

The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs’ true effectiveness, a new analysis has found.
In published trials, about 60 percent of people taking the drugs report significant relief from depression, compared with roughly 40 percent of those on placebo pills. But when the less positive, unpublished trials are included, the advantage shrinks: the drugs outperform placebos, but by a modest margin, concludes the new report, which appears Thursday in The New England Journal of Medicine.

I have occasionally watched Dr. Oz's show and for the most part he seems to endorse healthy eating and lifestyle. I see him mainly as an entertainer and not an informer since he is a cardiac surgeon. For the most part, I wouldn't go to a cardiac surgeon to discuss general health problems. I don't know why other people can't dismiss his more questionable advice. It seems like his critics( some allied with Monsanto) are worried that his advice will be taken as gospel.

Now, if Dr. Oz had endorsed diet/supplements over medicine for heart disease than there might be a problem since one would expect a cardiac surgeon to be somewhat of an expert in this area. My father, by the way, had two carotid arteries blocked (one 80% and the other 20%) after about ten years of taking blood thinners and cholesterol lowering medications. My father might have benefited from relying less on medication and more on diet.

I think it would behoove his critics to do a Google search on any health condition and see what sites are the most popular. The ones that seem to be first on most of my searches are the Mayo Clinic and Web MD, two of the most conservative sites there are. For the most part people are searching for the most trusted and objective information. This alternative medicine scare is a non issue.

With regards to alternative medicine I have had some success, more than I have had with traditional medicine. My experiments with sleep and diet augmentation have been helpful to a greater degree than pharmaceuticals. Personally at this point, I wouldn't place excessive faith in any cure, alternative or traditional. One needs to question everything and follow the money trail whether it is someone like Oz, doctors in general, or the pharmaceutical companies. In the end, I have more of an issue with my psychiatrist who tried to push Cymbalta (samples supplied by the pharmaceutical company) that would have cost me $500 a month, than Dr. Oz and his peddling of fish oil for stress.

Is there such a thing as a "bipolar spectrum"? I am undecided on this question and welcome any new perspective. Joel Paris, a personality disorder expert, had written a book on the topic in 2012 and tried to make the case that much of what falls in the "bipolar spectrum" is really a problem with "emotional dysregulation"( borderline personality disorder). He also tries to make the case that Bipolar I,Bipolar II and melancholic depression are diseases despite the lack of any physical tests or genetic evidence.

Its crucial to remember that that the bipolar spectrum is an unproven concept. The alchemy that turns depression, impulsive disorders, childhood behavioral disorders, and personality disorders into bipolarity depends on entirely superficial resemblances between observable behavioral symptom patterns. Its not based on any basic understanding of the disease process.

For the most part the book was a logical and interesting critique of the "bipolar spectrum" concept however I had the feeling that, given the fact that Paris was a personality disorder expert, he might be jealous of all the money that goes to fund bipolar spectrum research and would like to divert some of those resources.

I have been diagnosed with Dysthymia and Psychotic depression and might, according to this book, be labeled with Borderline disorder. To label everyone with mood instability as Borderline or another personality disorder seems just as unreasonable as labeling everyone as bipolar given the fact that personality disorders aren't defined much better than Bipolar disorder. In my case the instability could be explained by PMS and an extreme diurnal mood variation. According to Paris my personality disorder should have abated by middle age however I don't think my condition has improved much since it began.

Finally, affective instability has a different outcome from bipolar disorder. It gets better with time, but never completely disappears. It remains the chief complaint of patients with personality disorders who are followed into middle age.

Patients with unstable mood experience daily life differently than bipolar patients according to Paris.

They describe their life as on an "emotional roller coaster." they wake up feeling normal but get rapidly upset by each and every life event . In the course of the day, they feel sad and hopeless, angry to the point of uncontrollable rage, or happy enough to briefly feel slightly "high". Each mood lasts for a few hours. These emotional reactions are intense, and can take some time to "come down" from them.

He seems to believe that the only true diseases in the DSM are melancholic depression(severe depression) and Bipolar I/II. One could still argue that the previously mentioned categories are still quite arbitrary and vague in comparison to many other diseases. Further more the definition of severe depression varies between different researchers and "severe" depressives only fared slightly better on antidepressants according to some experts(Moncrieff) who have written critiques of antidepressant research.

The relationship between diet, inflammation and depression

A new study by the Centre for Addiction and Mental Health (CAMH) found that the measure of brain inflammation in people who were experiencing clinical depression was increased by 30 per cent. The findings, published in JAMA Psychiatry, have important implications for developing new treatments for depression.

A growing body of evidence suggests the role of inflammation in generating the symptoms of a major depressive episode such as low mood, loss of appetite, and inability to sleep. But what was previously unclear was whether inflammation played a role in clinical depression independent of any other physical illness.

More research has come out which supports the link between inflammation and depression. While this link hasn't been confirmed my experience has piqued my interest in the topic. For about fifteen years I have been experimenting with Ayurveda which is a form of medicine which originated in India a thousand years ago. In Ayurveda the world is divided up into three different categories(doshas in human body), Vata, Pitta and Kapha. Vata is associated with air, Pitta with fire/water and Kapha with water/earth. In the human body the various categories govern certain functions and areas. Pitta governs metabolism, heat regulation and the immune system. It is located in the eyes and small intestine. Various tastes/qualities are said to balance the doshas. Pitta is said to be balanced by sweet, bitter, astringent and coolness.

For many years I have experimented with Ayurveda and discovered that balancing Pitta was very helpful, even more than balancing Vata which is associated in Ayurveda with the nervous system. Balancing Pitta is helpful especially in regards to anxiety, irritability and depression. Perhaps Pitta's association with inflammation in Ayurveda might explain this. In addition, Ayurveda recommends a vegetarian diet for a Pitta type of imbalance, a vegetarian diet has been shown in western medicine to help with inflammation.

Balancing Kapha, which is said to be localized in the stomach, has been helpful in regard to lack of motivation and energy. Balancing a dosha can aggravate another. Whenever I balance Kapha I notice Pitta becoming imbalanced. Balancing or pacifying Kapha can increase irritability which is a Pitta imbalance. In Ayurveda there are different methods of balancing more than on dosha. One way is to balance Vata which is believed to govern the other doshas. The second method is to balance the two using the qualities that balance the two doshas. In the case of Pitta and Kapha they are both balanced by bitter and astringent tastes. While this balancing act can be consciously performed I think it is also subconsciously performed when we have desert after a meal that has had too much salty and sour taste to it.

Somewhat interestingly healthy food tends to be higher in bitter and astringent qualities while junk food is higher in salty, sour and sweet tastes. According to Ayurveda salty, sour and sweet all balance Vata which is associated with the nervous system and stress. Perhaps this preference is one reason why western cultures seem to have more problems with inflammation and depression.

Could depression be a form of adaptation?

The most recent theory on depression is that it could be some type of adaptation. I have written regarding this idea before in a post titled Evolutionary origins of the depression epidemic. The author of the book in that previous post was making a similar argument. He believed that depression was not a pathological condition but a way of adapting to stressful conditions. For example if a person lost a job and became depressed the depression could perhaps be a way of conserving energy or the depression might be suggesting that a person should change their goals.

In that previous post I wrote that depression in its milder forms could conceivably be seen as an adaptation however in its more severe forms not very likely. After all severely depressed people have problems functioning on a very basic level and aren't analyzing problems in the most objective or productive manner. Often depression seems to reduce flexibility and brainstorming. The only solution for many severely depressed people is suicide. It is more accurate to say that majorly depressed people obsess more than they analyze.

I, for example, have experienced chronic depression for most of my life and while being rather obsessive and analytical still have not gained  much insight into why I have felt depressed for most of my life. I have experienced many periods where I felt normal and quite productive but it wasn't necessarily due to some kind of insight. Those normal periods just happened and sometimes they occurred in a diurnal pattern or in a menstrual pattern which makes no sense in regard to the theory. Why would one person feel severely depressed in the morning and normal at night for a number of days? Why would I often feel normal to euphoric when I had my period? Various levels in hormones and their effect on neurotransmitters seem more likely.

This most recent research is suggesting the adaptation theory once again only instead of conserving energy depression focuses our energy obsessively on one thing and supposedly solves it.

The research suggests that depression may be a natural condition in which the mind concentrates involuntarily on a complex issue to the point where it allocates resources to analyzing the problem at hand, diminishing concentration on other aspects of living, perhaps giving rise to disrupted eating, sleeping and social interaction that are associated with depression.

This theory seems to assume the idea that depression is due to excessive stress which is debatable. One can feel more stressed pursuing a goal and yet have a reduced level of depression.  For example, I have given up on a number of goals which I found stressful and have not noticed any positive change in my level of depression. In fact, I felt worse for giving up on my goal. A proponent of this theory might also argue that I haven't made the right changes in my life. How does one falsify this theory if this is their answer. Additionally, the proponents of this theory keep pointing out that there is no conclusive evidence of pathology in major depression. True but it doesn't necessarily follow that pathology won't be discovered in the future. The fact that depression increases the likelihood of dementia is sufficient reason to keep looking for pathology in regards to depression.

CBT: a questionable form of therapy for depression

CBT is a therapy based on the belief that one's negative illogical thoughts can cause depression and correcting them can treat the depression. CBT therapy is usually performed with a therapist however now computer programs are being created to help depressed individuals. While CBT therapy is endorsed by psychiatry it has a number of problems.

Depression is known to cause distorted thinking so what comes first the depression or the distorted thinking? CBT doesn't clarify this issue. It just says that correcting illogical thinking treats the disorder.

CBT therapy has been shown to be as effective as antidepressant therapy and prevents relapses better than drugs. The problem with this is that antidepressant therapy isn't all that effective. Antidepressants are, in reality, only slightly more effective than a placebo. Additionally, since major depression is cyclical how does one know for sure if the treatment was actually helping. Many experiments are performed over rather short periods of time and a certain percentage of people will have spontaneous remissions. This of course could be the same issue for antidepressant trials.

Experiments involving CBT vs antidepressants are not double blind which is considered essential for the highest level of objectivity. If the researchers and the patients know what type of therapy is being performed objectivity is diminished.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in

Researchers say that brain scans show that CBT "works" and yet brain scans are not considered a reliable way to diagnose mental illness. People with mental illness often have more than problem such as depression and ADD. This confounds diagnosing a mental disorder or saying confidently that an individual is in remission. This excerpt from Scientific American explains the problem.

During testing, the system analyzed the shapes of brain regions in each test scan and assigned it to the group it most resembled. The scientists checked its work by comparing the new labels on the test scans with the original clinical diagnoses. They repeated the procedure several times with different randomly generated sets. When the system chose between two disorders or one ailment and a clean bill of health, its accuracy was nearly perfect. When deciding among three alternatives, it did much worse.

The basis of CBT doesn't explain how people with a rapid cycling form of bipolar disorder cycle between depression and mania. Do they start off having negative thoughts during a depressive episode which eventually cycles with mania  and the mania consequently produces delusional thinking? CBT has not been shown to be effective for preventing depressive episodes in bipolar disorder.

CBT has given no biological explanation for how it works and yet implies that possibly negative thoughts might exacerbate stress which in turn precipitates a depressive episode. Even though stress has long been thought to cause depression stress(HPA activation) is not distinctive to just depression. Stress is implicated in numerous health problems in a rather vague manner. To further complicated matters what is stressful to one person isn't stressful to another. Consequently it is complicated to study stress.

In the end CBT emphasizes that depressed people are responsible for their depression which is still questionable in the eyes of science.

Fish intake might improve antidepressant response

Approximately half of the people suffering with depression don't respond to SSRIs. Recently a group of Dutch researchers discovered that adding fish oil to antidepressants increases the response rate.

According to a lead researcher they saw that depressed patients had an altered metabolism of fatty acids, and this altered metabolism was affected by stress hormones. In the experiment the researchers planned on examining the relationship between depression and fatty acids, and hormones such as cortisol.

They took 70 patients with depression and compared them to 51 healthy controls, by measuring their fatty acid levels and cortisol levels. They then gave the depressed patients 20mg of an SSRI daily for 6 weeks, and in those who did not respond to the SSRIs the dose was gradually increased up to 50mg/day. Fatty acid and cortisol levels were measured during the trial.
They found that the MDD patients who didn't respond to the SSRI also tended to have abnormal fatty acid metabolism, so they checked the dietary habits of all those taking part in the trial. Fatty fish is rich in fatty acids, such as the well-known Omega-3 DHA. So the researchers looked at the amount of fatty fish in the diet of all involved in the trial. They categorised the patients into 4 groups, according to their fatty fish intake, and they found that those who took the least fish tended to respond badly to anti-depressants, whereas those who had most fish in the diet responded best to anti-depressants. Those who ate fatty fish at least once a week had a 75% chance of responding to antidepressants, whereas those who never ate fatty fish had only a 23% chance of responding to antidepressants.

There were a couple of problems with this study. For one thing the study was on the small side and should be replicated with a larger one. A second problem is that the researchers appeared to know the fatty acid status of the depressed patients so they might have subconsciously altered the depression scores in order for their hypothesis to be proven correct. How the depression scores were measured is unclear from the article.

Andrew Stoll was one the first researchers to notice the antidepressant effect of fish oil. He theorized that fish oil might effect the composition of nerve cell membranes and consequently neurotransmission. Barry Sears, author of " The Zone", was another researcher who mentioned that stress could effect the type of fatty acids. They both probably inspired this study. I did not read the original article so if you are curious you will have to pay for the article through ECNP.

One way exercise could act as an antidepressant

Researchers have recently discovered that there is an enzyme in muscle that detoxifies a substance which tends to be high in the mentally ill. The substance Kynurenine is produced when an individual is exposed to stress. Exercise has long been considered as an antidepressant with stress reducing properties. This could perhaps be one explanation and a new way to target depression.

The researchers discovered that mice with higher levels of PGC-1a1 in muscle also had higher levels of enzymes called KAT. KATs convert a substance formed during stress (kynurenine) into kynurenic acid, a substance that is not able to pass from the blood to the brain. The exact function of kynurenine is not known, but high levels of kynurenine can be measured in patients with mental illness. In this study, the researchers demonstrated that when normal mice were given kynurenine, they displayed depressive behaviour, while mice with increased levels of PGC-1a1 in muscle were not affected. In fact, these animals never show elevated kynurenine levels in their blood since the KAT enzymes in their well-trained muscles quickly convert it to kynurenic acid, resulting in a protective mechanism.

In comparison to medication I have received more benefits from exercise with respect to stress reduction. Many antidepressants can also reduce stress however they have side effects, one of which is sedation with a loss of motivation.

Do antidepressants cause weight gain?

Antidepressants have been associated with weight gain however a new study refutes that idea.

Yet according to a study published a few days ago in the online issue of JAMA Psychiatry, this should not have happened. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. ..... Conclusion: The researchers said that patients should not be scared of taking antidepressants because they think they will gain weight. [1]
Weight was gained among those who had depression, but according to the author, only among those who had what she described as atypical depression, a depression characterized by increased appetite.

The majority of my 50 pound weight gain started 4 years ago after I stopped taking Wellbutrin. Ten of the 50 pound weight gain could be due to taking Risperdone in the last year. I doubt the author's speculation about an increase in appetite. My calorie intake was about the same over that four year period since I am rather rigid/consistent when it comes to eating. The fact that the weight gain could be related to atypical depression could be supported in my case however I didn't gain much weight while on Wellbutrin. Atypical depressives can also gain weight independent of calorie intake.