Human beings are nothing if not predictable. The entirety of modern medicine turns on this fundamental truth. The med school mantra is, “Common things occur commonly.” This basically means that pathology can be identified, catalogued, and predicted based upon past performance within a population. The modern phenomenon of Evidence-Based Medicine is its ultimate result.

Mental Health & Mass Shootings

We perceive that our world is going to hell in a hand basket, and who can blame us? Every couple of days our phones, tablets, TVs, and laptops scream about some fresh new egregious crime. Images of distraught families and poignant crime scenes littered with shell casings pipe straight into our eyeballs the moment the smoke clears. However, a lot of that perception is simply packaging.

Statistically, crime in America was markedly worse in the 1980’s and 1990’s. It was just that we lacked the means to experience it quite so viscerally back then. Nowadays the narrative comes packaged and promoted so as to shape public opinion and subsequent policy. In no place is this axiom on more stark display than in the modern scourge of mass shootings.

Categorizing

One could be forgiven for believing that anybody who would shoot up an elementary school is, by definition, mentally ill. Simply put, emotionally healthy folk should lack the capacity for such sordid stuff. However, many in the psychiatry world disagree. A recent article in Psychiatry Times made a compelling argument that mass shooters are more accurately labeled terrorists than mentally ill. This article asserted that diagnosable mental illness was found in as few as 20% of mass shooters and in only 3% of violent criminals overall.

Psychiatrists rightfully despise the term crazy. These statistical categorizations typically reflect a justifiable effort to de-stigmatize mental illness and prevent discrimination against those with psychiatric diagnoses by the uninitiated. For the most part, however, this is an issue of semantics. While frank psychosis (a pathological disconnection from reality) is only seen in about ten percent of modern mass shooters, they could all be diagnosed with something.

Tough to Predict

Mass shooters nonetheless remain difficult to predict. According to the National Institute of Justice, in the U.S. males outnumber females 24 to 1. The mean age is 34, and a bit more than half are Caucasian. Most mass shooters have a criminal history, and around a quarter have a history of domestic violence.

Many of the more spectacular mass shooters are young, disaffected, prone to violent emotional outbursts, and acutely suicidal. While many of these killers are indeed impulsive young people, that is not always the case. Stephen Paddock was a wealthy 64-year-old who fired more than 1,000 rounds into a crowd at the open-air Route 91 Harvest music festival in Las Vegas in October of 2017. He ultimately murdered 60 people before killing himself. However, Stephen Paddock was an outlier. In Columbine, Buffalo, Sandy Hook, Marjorie Stoneman, and Uvalde these mass shooters shared some common characteristics.

Mental Health and Mass Murder

Psychiatrists characterize mental illness using the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders-5th Edition-Text Revision). This tome evolves over time. Certain sexual behaviors, for instance, once considered aberrant disease states in eras past, became socially acceptable today.

Arguably the single greatest psychiatric predictor of egregious behavior is Antisocial Personality Disorder or ASPD. Per the DSM-5-TR, diagnosis of ASPD requires at least three of the following traits:

• Failure to conform to social norms and laws, indicated by repeatedly engaging in illegal activities.
• Deceitfulness, indicated by continuously lying, using aliases, or conning others for personal gain and pleasure.
• Exhibiting impulsivity or failing to plan ahead.
• Irritability and aggressiveness, indicated by repeatedly getting into fights or physically assaulting others.
• Reckless behaviors that disregard the safety of others.
• Irresponsibility, indicated by repeatedly failing to consistently work or honor financial obligations.
• Lack of remorse after hurting or mistreating another person.

Minors and Mental Health

Additionally, to earn the diagnosis of ASPD a person must be at least 18 years old, show evidence of Conduct Disorder prior to age 15, and not carry a concomitant diagnosis of schizophrenia or bipolar disorder that could explain the aberrant behavior. Conduct Disorder comprises a similar condition typically diagnosed in childhood. Between 25 and 40% of kids diagnosed with Conduct Disorder will progress to ASPD.

The easiest way to get your head around ASPD is to view this as a congenital lack of conscience. Those thusly smitten typically are unable to empathize with the suffering of others. They often torture animals, and most ultimately end up in prison. The few full-bore ASPD patients I met in in-patient settings during my medical training were amazing to behold. One sweet-looking kid nearly killed his foster mom with a pencil.

The details concerning diagnosis and treatment of these problems are markedly more complex than I have alluded to here. Modern medicine remains complicated, and psychiatry poses one of the most labyrinthine facets of the craft. However, ASPD is one of those rare psychiatric problems that does seem to be a decent predictor of dangerous behavior.

The Problem

The trick is to identify these sociopaths and effectively intervene before they act upon their sociopathy. In a free nation that respects individual rights that is a Gordian chore. Balancing public safety against individual rights is a timeless quandary. Reality is that mass shooters are vanishingly rare, and this makes identifying them before they act all but impossible. Most mass shooters do still show indicators prior to the event, and it is easy to say that the police or schools should have intervened in retrospect. However, the devil is in the details.

You can’t lock up a 16-year-old boy for the rest of his live because he obsesses with violent video games and set fire to the neighbor’s cat. This is despite the fact that such toxic stuff does indeed seem to be a common foundation for a lot of young mass shooters. Additionally, the road to hell comes paved with unbalanced people who got appropriate mental health treatment and still did something horrible anyway. Major Nidal Hasan, the 2009 Fort Hood shooter, was himself a psychiatrist. Psychiatry, like any other human pursuit, is an inexact science.

Beyond the Data

Between 1966 and 2019 three quarters of mass shooters used handguns, while the remainder employed a rifle. The less durable members of society obsess over assault weapons bans and background checks. However, the dispassionate observer appreciates that the modern phenomenon of mass shootings is driven by the deterioration of the family and our utter absence of a moral compass. When kids are raised to believe that morality is relative and life is cheap, we really shouldn’t be surprised when a small but statistically significant percentage grow up to become monsters. Your mileage may vary, but that’s why I carry a gun myself whenever I’m not asleep or in the shower. We do indeed share the world with some fascinating/terrifying folks.