Reconstructing a Troubled Mind After Virginia Tech

There’s going to be a lot of discussion and speculation about the tragic events at Virginia Tech.

Ten years ago I became very involved with the media after a tragic shooting at the Capitol building by a man suffering from mental illness, and so I know the questions and the second guessing that will go on.

I have, of course, not examined the alleged perpetrator of the events on Monday, but I have received a great many questions about what I think may have been wrong with him.

I did not want to answer until I had put together as much material as I could.

From the reports that I have received we can begin to construct a very plausible scenario.

The first thing to say is that it is very unusual for people with mental illness to commit major violent crimes.

Second is that many of the most horrendous serial killers have not had a psychiatric disorder at all. That may sound odd: how could someone do something awful and not be sick? Some people do bad thing because they are bad. Not because they are suffering from an illness.

Third, it is always easy to be wise after the event. Sometimes when people are mentally ill the illness itself stops them from communicating, especially to health care providers. Many people have admitted to me that they were hearing voices telling them to say nothing to me or to deny their existence. That is why we always watch to see if people may be attending to auditory hallucinations, or if they are preoccupied by internal stimuli.

Many years ago I knew a man who was obviously ill but would reveal nothing. Without tangible evidence of mental illness the courts told him to go on his way. The experience and gut instinct of one of the world’s top psychiatrists counted for little in the eyes of the court: they wanted evidence.

So the man left and immediately threw himself under a train. It was only later that his family found his writings and drawings about his fear that a demon was pursuing him. The poor man had been hallucinating and delusional all along. There are many ways of telling the difference between someone having evil experiences and someone with a mental illness: there are many people who specialize in such things.

I have been looking at the reports in the media that agree on certain points, and I am going to pick out the ones that really jump out at me as a professional.

• “He sat right beside the door, and as soon as class was over, he left."
  
• “On the first day, when the instructor asked students to write their names on a sheet of paper and hand it up, Cho wrote a question mark.”
  
• “Always wore a hat and sunglasses.”
  
• "He never looked up.”
  
• “He never looked anyone in the eye. If you even say hi, he’d keep walking straight past you."
  
• “He often spoke in a whisper, if at all.”
• "He would keep his headphones on a lot."
  
• "It was like he was carrying on a conversation with himself."
  
• “Nobody knows him really, he’s always quiet. When I talk to him, there’s no response."
  
• “The teacher had addressed a question to him and he really just stared off into space. He didn’t even recall acknowledging that she was talking to him.”
  
• “He disappeared from class.”
  
• “Taking secret pictures of his classmates.”
  
• “A loner.”
  
• “Angry, menacing, disturbed and so depressed that he seemed near tears.”
  
• “Rambling multi-page "manifesto" directed against the rich, the spoiled and the world in general.”
  
• On the day of the tragedy, “Cho’s face was blank and expressionless. There was always just one look on his face.”

• And in 2005 he was declared mentally ill and said to “present an imminent danger to himself as a result of mental illness."

We do not yet know what diagnosis and treatment were offered, but he does not seem to have followed up. As with the man who jumped in front of a train, people with persecutory delusions can be very good at concealing them.

If we look back over these items, it is likely that he sat by the door so that he could escape from some perceived threat; he probably had real questions about who he was; the hat and sunglasses are commonly worn for “protection” and the avoidance of eye contact is usually because people are preoccupied by things going on inside their heads, or because they fear that you can see through their eyes. Many people who are experiencing auditory hallucinations use portable music systems to drown out the voices:  I have known more than one person who has had hearing damage from cranking up the volume. He probably was carrying on a conversation with the voices in his head. The avoidance and staring into space are usually signs of being preoccupied with internal experiences. The pictures would have been used to fuel his paranoia. The blank, expressionless face is a classic feature of one of the schizophrenic illnesses as is the social isolation. We would have to see the “rambling manifesto” to be sure, but the “rambling” could be a sign of what is known as “thought disorder” or “communication disorder.”

Several previous killers have been found to have different forms of brain disease. Taken together these clinical features are most likely the signs of a major psychiatric illness rather than something like a brain tumor.

The other thing of importance is that at least one person said that he seemed to be “mean,” so there may have been more than just a psychiatric or neurological illness going on.

Time will tell, and this is so far all informed guesswork. But at this point it makes some sense of this tragedy.

There will inevitably be a lot of speculation about what could or should have been done. But there is an extra factor that needs to be considered: the law is designed to allow people’s freedom. I have been in mental health courts on countless occasions and it is rare for a person to be committed for involuntary treatment unless there is really compelling evidence of a person being a danger to themselves or someone else.

Many people will feel that they should have noticed the signs of mental illness. Well hindsight is always 20/20 and I can tell you that the greatest experts have sometimes been fooled. If I, or one of my colleagues had, by some strange chance, run into this young man, would we have been able to diagnose him? As with my patient all those years ago, I would have been pretty sure, but I couldn’t prove it. And without that proof it is very hard to take any action.

Let me finish by saying again that the vast majority of people struggling with mental illness are not dangerous. The job of professionals is to find the ones who are, and to this day we have no reliable way of doing it.