Psychological Implications of the Connecticut School Shooting

A lone gunman killed 20 children and 6 adults including himself at a Connecticut) School He used guns registered to his mother. The emergence of ASD and PTSD Acute Stress Disorder and/ Post Traumatic Stress Disorder) were identified as happening after a major incident such as this one. The symptoms that can be present in this situation were reviewed as well as some possible long term effects. The grieving process was also discussed. In the aftermath of such situations, attention is often focused on people with mental illness who might have the potential do do violence and/or commit a copycat crime even though in retrospect this is very small proportion of the population.The gun control issue and related psychological factors were also discussed.

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.

 

Let’s Talk About Suicide

Suicide is the 11th leading cause of death among persons over age 10. Patients with Major Depression or Bipolar Depression have a 20-60 fold increase of mortality rate over the general population. The role of medication and psychotherapy is can be important in preventing suicides. This topic will be discussed in future blogs and is the theme of the annual meeting of the
American Academy of Psychoanalysis and Dynamic Psychiatry which will be held in San Francisco Aug 16-18 2012.

Both attempted and completed suicides represent a major clinical and public health challenge. The CDC has ranked suicide as the 11th leading cause of death among persons over age 10 (33,289 suicide deaths were reported in the United States in 2009.

In a recent article in Psychiatric Times Dr. Tondo and Baldessarini  noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with Major Depression or Bipolar Depression have a 20-26 fold increase of mortality rate over the general population. It was also stated in this article the fact than fewer than 1/3 of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further state that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several recent studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity—all of which are particularly prevalent in Bipolar Disorder and may contribute to the unusually high suicide risk in persons with this disorder. In patients with such conditions (especially young patients), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict and other psychological issues can all contribute to self destructive behavior which can result in suicidal behavior. Suicidal gestures which may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyber bulling has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue not only for mental health professionals but for leaders in the military, teachers, parents and for us all. We also need to recognize that there are many mental health issues that have to be faced in the aftermath of a suicide.

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16-18 meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (of which I am the current President) which will be held in San Francisco (just prior to the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can contact me  if you have any questions at this time

The Connection Between Depression and Stroke

A recent article published in JAMA has concluded that depression is associated with a significantly increased risk of stroke morbidity and mortality.
This important topic is further discussed.

A recent study published in the  Journal of the American Medical Association  concluded that depression is associated  with a significantly increased risk of stroke morbidity and mortality. This means that if you have depression you are more likely to have a stroke and die from a stroke as compared to a situation where you didn’t have depression .

This is quite relevant to a large number of people since depression is quite prevalent in the general population. It is estimated that 5.8% of men and 9.5% of women will experience a depression e episode in a 12 month period. The lifetime incidence of depression has been estimated at more than 16% in the general population.

This research study was by Dr. An Pan  and four colleagues from the Harvard School of Public Health and Harvard Medical School. The research was a meta-analysis and a systematic review which meant that the authors studied research of many studies on this subject The ended up looking at 28 prospective cohort studies comprising 317,540 participants which reported 8478 stroke cases during a follow-up period ranging from 2-29 years.

Their scientific analysis of the data demonstrated that depression is associated with a significantly increased risk of developing stroke. They also found a positive association of depression with a fatal stroke.

The authors discussed a variety of mechanisms which depression may contribute to stroke. Depression has known neuroendocrine effects. For example t there is a dysregulation of HPA axis ( hypothalamic-pituitary-adrencortical axis which can cause high blood pressure. It has been shown that depression effects platelets and leads to  dysfunction which causes abnormalities in the clotting mechanism. There are also abnormalities in the immune and inflammation systems which could influence stroke risk..

Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, lack of medication compliance and obesity, all of which may contribute to stroke.

Depression has already been associated with coronary heart disease, diabetes and hypertension. (See an earlier blog on depression and heart disease as well as another blog which raised the question whether people with depression should be taking aspirin to prevent heart attacks).

The data from the recent JAMA study also suggested that it is possible that antidepressant medication may be associated with stroke risk but this may be a false impression since medication use can be a marker of depression severity and many of the studies that the authors looked at lacked information on dose and duration of medication use.

There are some limitations of this study and the findings don’t prove 100% that depression causes stroke. I would imagine that it is conceivable that the genetic markers for stroke and depression could be located in close proximity leading to such impression of this effect. However even if there is no causative effect (  although I believe the research strongly suggest one ), the association of these conditions clearly calls out for great attention being paid to this association. There is an opportunity for doctors who see patients who are at a high risk for stroke to be referred for treatment of depression. Also patients who are being treated for depression should be encouraged to be seek medical attention and assistance in reducing all the other risk factors for stroke whenever possible.

Depression is a serious condition and is very treatable. Treatment works! Patients who have depression should be treated whether or not they are at a higher risk for stroke and other diseases.

We’re Not Providers For Consumers/Clients

The dictionary definition of ” consumer, client, patient, provider and care giver ” are examined under the thesis that “we are not providers consumers or clients. The special bond of psychiatrists as well as other mental health professional with their patients is noted and the potential erosion of that relationship is discussed.

Paul Krugman

Recently Paul Krugman wrote an interesting piece in the NY Times titled, Patients Are Not Consumers . In it he wonders what has gone wrong with us if receiving health care is like buying a car?

While he did not discuss specifically the treatment of mental illness and psychotherapy, those of us in this field have similar concerns.

Thinking about this article sent me to the dictionary (Webster’s Unabridged 20th Century-2nd Edition) to look up a couple of words that are used in this debate.

Consumer– A person who uses goods or services to satisfy his need rather than to resell them or produce other goods with them.

Client– A dependent one under protection or patronage of another person or company in its relationship to a lawyer, accountant etc, engaged to act on its behalf, loosely, a customer.

Patient– A person receiving care or treatment; especially, a person under the care of a doctor; as the physician visits his patient morning and evening.

It is wonderful to observe how inapprehensive those patients are of their disease- Blackmore

Provider– One who provides, furnishes or supplies; one who procures what is wanted

Care giver– (There is no single word as such)

Rather than further try to analyze or argue why and how these words should be used, I would like to present a few real situations and ask you to consider which words seem most appropriate :

1-Mrs. Jones as you know I check blood levels of Lithium and do other routine blood tests on my (choose one – patients, clients , or consumers) and I  have just received the results back. While the lithium level is right where we want it, I do note that your TSH is high which indicates that you may have a hypothyroid condition which could be contributing to your recent depressive symptoms. I would like to call your (choose one – primary care provider, medical care giver, health care provider, primary care physician) and I would like you to make an appointment with her.

2-(Phone call) Is this the emergency room (choose one – provider, care giver,  physician)? My (choose one- consumer, client,  patient) has just informed me that she took an overdose of tranquilizers and antidepressants which I have been prescribing for her and I have arranged for an ambulance to bring her to the hospital.

3-It appears that you are jealous of the other (choose one – consumers, clients, patients) in the waiting room as you were jealous of your siblings and you want to leave me as you left your other (choose one : providers, caregivers,  therapists)

I understand that some of the words with which many of us are uncomfortable  have come from the people who are trying to develop healthcare systems for large numbers of people. For  them, such words as providers, caregivers, consumers or clients may better suit the concepts  which they are dealing with in the abstract. One might argue that the meaning of words may change but if one is clear in regard to their own identity, perhaps it isn’t a big deal if a different word is used. If I have established a doctor-patient relationship with a patient and I am clear as to my code of ethics why should I get upset if a patient or an insurance company calls me a provider ? The problem is that there is a blurring of the expectations between  a casual sale of an automobile to a consumer and the expectation of a physician or other health care professional  who is entrusted with the care of a patient.

There is a special bond that physicians have with patients which has its origin with the Hippocratic Oath. It has come to mean a selfless dedication to doing everything in one’s power to help the person who has trusted us with their healthcare. There may be obstacles and complications related to third party payers, treatment being shared by multiple specialties and disciplines, patients being guided by information from the Internet etc, but we still view the patient as someone we owe a special obligation to do our absolute best to assist. The objective and subjective meaning of the words provider, client, consumer, etc. do not convey the relationship which we feel towards our patients and which they usually feel towards us . In the past many of our non-physician colleagues in the mental health profession also used this model and have a similar bond with their patients.

My generation of psychiatrists and other mental health professionals, I believe are clear in our  role and the expectations of our patients. However, it is somewhat more confusing for young people just out of training especially when they take positions in Mental Health Clinics where the newer terminology may be used. It may be easier for a young psychiatrist who has had some experience in medical school and during internship (PGY 1 year) where he or she has functioned in life and death situations.

Those experiences become the underpinning of how they will view the people that they will treat. Certainly that can become eroded if they are in an environment where other models are used. I also believe that it may be more difficult for young social workers and psychologists to appreciate the differences if they have only worked with these new terms during their training.

In ten years from now will this be a moot question?  Or will our attention to this debate now and the public’s desire for special relationships with the people who provide their health care treatment (physical and mental ) prevail in reality and in the terminology which we use?

I would welcome comment from anyone on this topic. I also am especially interested in the experience of our international readers of this blog (who make up about 50 % of the visitors to this site) Are there new words in other languages replacing doctor, physician and patient? Is this being discussed in other countries?

Refusing To Continue Dialysis

An 82 year old grandmother with her family’s support requests termination of hemodialysis that she is receiving for end stage renal disease.
A second psychiatric opinion determines that she really does not want to die and she had mistakenly believes that is what her family wished. After a family meeting, the family is able to readjust their support of her and she continues on dialysis. There is a brief review of various forms of dialysis treatment and the fact that Medicare pays for this treatment regardless of the age of the patient.

The Women Who Did Not Mean “NO”

A case history *

An 82 year old Italian speaking grandmother with a very dedicated and loving large family was coming to the hospital three times a week to receive hemodialysis for kidney failure. DialysisThis is a four or five hour process where tubes are attached to her blood vessels through a special connection called a fistula and her blood is run through a machine with a filter system to clean it of toxins since her kidneys are not functioning properly. She was viewed as having been depressed for approximately two years and frequently would be reluctant to come for her dialysis. She was on Prozac, an antidepressant, for about one year with no apparent change.

Recent Complication

Most recently the patient’s fistula clotted and there were no more readily available sites to reconnect the equipment. Surgery was recommended to create a new vascular site for the dialysis but the patient refused to go along with this procedure. The family explained that she had suffered enough  and now just wanted to stop the dialysis and peacefully pass away.

Psychiatric Consultation

The first psychiatrist who saw the patient interviewed her with the family as translator and also understood enough Italian to confirm that this was what the patient was requesting. There was no evidence of significant depression or overt psychosis. The family was very sad about this decision but felt strongly about respecting her wishes.

Second Opinion

Because of the finality of such a decision, it was not unusual to have a second psychiatrist see the patient and I was asked to see her. Rather than use the family as a translator or have them be present during the interview, I asked a nursing supervisor who spoke Italian to do this task.

The patient related well and showed a clear sensorium, very much aware of her surroundings and the situation. She said that she did not want to die and enjoyed being at home visiting with her grandchildren and watching television. She was not in significant discomfort. However she believed that her children believed it was time for her to move on. She wrongly thought that her medical care was a financial burden to her family. She also believed that family members who brought her for dialysis were taking valuable time away from their jobs and family. She even could give examples of things that they had said to confirm this. She believed that the proposed surgery to establish her dialysis site was very unusual and the doctors resented doing it . (Both of these ideas were not true).

Therefore she thought that the right thing to do was to refuse the procedure and peacefully die. She viewed her family as respecting her statement that she did not want dialysis as proof  that she was a burden to them.

The Resolution

I needed to do some sensitive delicate follow-up work with the patient and her family to get the patient to accept the surgical procedure and continue on dialysis. Once the family understood that the patient enjoyed her life and was not ready to die , they become very supportive and determined to help her in every way that they could.  The family arranged a rotating schedule of drivers for her dialysis that included the grandchildren, which proved to very gratifying for all those concerned.

It should be mentioned that there are patients who decide to go off dialysis and end their lives. Most hospitals have a process usually in conjunction with a Hospital Ethics Committee where this can take place.

*This Case history is based on a case report in a  a book that I wrote with Dr. Maria Tiamson-Kassab titled Practical Guidelines in Psychiatry- Psychosomatic Medicine published by Wolters Kluwer/Lippincott Williams & Wilkins  2nd E dition (2009).

Additional Comments

In 1972 the US Congress passed legislation providing that Medicare would cover the costs of dialysis regardless of the age of the patient. An important part of the debate concerning this legislation was when an actual patient was put on dialysis in front of the Congressional Committee discussing this impending bill. The statistics on the prolongation of  lives in the United States because of the treatments now  available are quite dramatic. While most of these treatments are  done at dialysis centers, there are specific types of dialysis that allow it to be done at home with home dialysis or in an ongoing  continuous manner, known as Peritoneal_dialysisContinuous Ambulatory Peritoneal Dialysis (CAPD) ,  while a person goes on with their usual activities  Many  people undergoing this treatment  have  been able to maintain a  very good quality of life. However, the time on dialysis has obviously altered people’s life styles and so have the medical complications that  can occur with renal disease and the various treatments for it. There are also psychological sequelae of this medical condition and treatment. Advances in renal transplantation have allowed many people to come off dialysis after receiving a kidney transplant from a cadaver or live donor ( often a close relative ) This situation is a major life event and has it’s own  medical and psychological implications. Many psychiatrists and other mental health specialists, particularly psychiatrists who are in the recently certified sub specialty field of Psychosomatic Medicine are interested in these issues. I look forward to discussing this topic  in future blogs.

Your comments are welcome.