Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning | Psychiatry and Behavioral Health | JAMA Psychiatry

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While the problem is complex, it may present an opportunity to improve research, as well as inform public dialogue about what types of mental illness are actually associated with such mass tragedies.</p><h3>Observations</h3><p>Assuring the diagnostic accuracy of those who commit mass violence is challenging due to the retrospective nature of the analysis and lack of reliable psychiatric data. Psychiatric research has begun to use a dimensional approach that may be well suited to the study of mental illness in perpetrators of mass violence. This approach aggregates psychiatric symptoms into 3 domains of psychopathology: (1) internalizing, (2) externalizing, and (3) psychotic experience. This approach has practical clinical use and research support. A dimensional approach may help clear up misconceptions about the rate of psychosis in mass violence perpetrators, as well as reveal the most common dimensions of mental functioning associated with perpetrators.</p><h3>Conclusions and Relevance</h3><p>Improved research methods are needed to clarify and prevent mass violence. More precisely identifying the symptoms and mental turmoil of perpetrators may be associated with improved early identification and prevention. Because adolescence is a critical and formative period in which internalizing and externalizing problems arise, early interventions may have the best chance of reducing future mass violence.</p>" /><meta name="citation_journal_title" content="JAMA Psychiatry" /><meta name="citation_journal_abbrev" content="JAMA Psychiatry" /><meta name="citation_volume" content="80" /><meta name="citation_issue" content="2" /><meta name="citation_publication_date" content="2023/02/01" /><meta name="citation_issn" content="2168-622X" /><meta name="citation_publisher" content="American Medical Association" /><meta name="citation_reference" content="citation_title=The myth of school shooters and psychotropic medications.; citation_author=Hall RCW; citation_author=Friedman SH; citation_author=Sorrentino R; citation_author=Lapchenko M; citation_author=Marcus A; citation_author=Ellis R; citation_journal_title=Behav Sci Law; citation_year=2019; citation_volume=37; citation_issue=5; citation_pages=540-558; " /><meta name="citation_reference" content="citation_title=Psychotic symptoms in mass shootings v. mass murders not involving firearms: findings from the Columbia mass murder database.; citation_author=Brucato G; citation_author=Appelbaum PS; citation_author=Hesson H; citation_journal_title=Psychol Med; " /><meta name="citation_reference" content="citation_author=Blair J; citation_author=Schweit K; citation_publisher=Texas State University and Federal Bureau of Investigation, US Department of Justice, ; citation_title=A Study of Active Shooter Incidents, 2000-2013; citation_year=2014; " /><meta name="citation_reference" content="citation_author=Silver J; citation_author=Simons A; citation_author=Craun S; citation_publisher=Federal Bureau of Investigation, US Department of Justice, ; citation_title=A Study of the Pre-Attack Behaviors of Active Shooters in the United States Between 2000-2013; citation_year=2018; " /><meta name="citation_reference" content="citation_title=Integrating and differentiating personality and psychopathology: a psychodynamic perspective.; citation_author=Luyten P; citation_author=Fonagy P; citation_journal_title=J Pers; citation_year=2022; citation_volume=90; citation_issue=1; citation_pages=75-88; " /><meta name="citation_reference" content="citation_title=All for one and one for all: mental disorders in one dimension.; citation_author=Caspi A; citation_author=Moffitt TE; citation_journal_title=Am J Psychiatry; citation_year=2018; citation_volume=175; citation_issue=9; citation_pages=831-844; " /><meta name="citation_reference" content="citation_title=A hierarchical taxonomy of psychopathology can transform mental health research.; citation_author=Conway CC; citation_author=Forbes MK; citation_author=Forbush KT; citation_journal_title=Perspect Psychol Sci; citation_year=2019; citation_volume=14; citation_issue=3; citation_pages=419-436; " /><meta name="citation_reference" content="citation_title=Validity and utility of Hierarchical Taxonomy of Psychopathology (HITOP): III: emotional dysfunction superspectrum.; citation_author=HITOP Utility Workgroup; citation_author=Watson D; citation_author=Levin-Aspenson HF; citation_author=Waszczuk MA; citation_journal_title=World Psychiatry; citation_year=2022; citation_volume=21; citation_issue=1; citation_pages=26-54; " /><meta name="citation_reference" content="citation_title=Early childhood internalizing problems, externalizing problems and their co-occurrence and (mal)adaptive functioning in emerging adulthood: a 16-year follow-up study.; citation_author=Arslan İB; citation_author=Lucassen N; citation_author=van Lier PAC; citation_author=de Haan AD; citation_author=Prinzie P; citation_journal_title=Soc Psychiatry Psychiatr Epidemiol; citation_year=2021; citation_volume=56; citation_issue=2; citation_pages=193-206; " /><meta name="citation_reference" content="citation_title=Personality disorders and violence: what is the link?; citation_author=Howard R; citation_journal_title=Borderline Personal Disord Emot Dysregul; citation_year=2015; citation_volume=2; citation_issue=1; citation_pages=12" /><meta name="citation_reference" content="citation_title=Mass murders involving firearms and other methods in school, college, and university settings: findings from the Columbia Mass Murder Database.; citation_author=Girgis RR; citation_author=Rogers RT; citation_author=Hesson H; citation_author=Lieberman JA; citation_author=Appelbaum PS; citation_author=Brucato G; citation_journal_title=J Forensic Sci; " /><meta name="citation_reference" content="ICD-11 for Mortality and Morbidity Statistics. 6D10 personality disorder. Accessed August 7, 2022. https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/941859884 " /><meta name="citation_reference" content="citation_title=Prosocial behavior is associated with transdiagnostic markers of affective sensitivity in multiple domains.; citation_author=Contreras-Huerta LS; citation_author=Lockwood PL; citation_author=Bird G; citation_author=Apps MAJ; citation_author=Crockett MJ; citation_journal_title=Emotion; citation_year=2022; citation_volume=22; citation_issue=5; citation_pages=820-835; " /><meta name="citation_reference" content="National Threat Assessment Center. Enhancing school safety using a threat assessment model: an operational guide for preventing targeted school violence. Accessed November 7, 2022. https://www.secretservice.gov/data/protection/ntac/USSS_NTAC_Enhancing_School_Safety_Guide_7.11.18.pdf " /><meta name="citation_reference" content="Virginia Department of Criminal Justice Services. Virginia Center for School and Campus Safety and public safety services. 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class="hide tagmanagervalue" data-attribute="topics" data-value="Psychiatry and Behavioral Health, Violence" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="topicCode" data-value="5871, 5957" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="category" data-value="Review" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="journalClub" data-value="No" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentStatus" data-value="Locked" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articlePubState" data-value="Final" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentMedium" data-value="Article" data-type="string"></span> <div class="meta-article-type-wrap"> <div class="meta-article-type thm-col">Special Communication </div> </div> <div class="meta-date">December 14, 2022</div> <div class="meta-article-title-wrap"> <h1 class="meta-article-title ">Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning</h1> </div> <div class="meta-authors"> <span class="wi-fullname brand-fg"><a href="/searchresults?author=James+Knoll&q=James+Knoll" rel=nofollow target="_blank">James Knoll IV, MD<sup>1</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Park+Dietz&q=Park+Dietz" rel=nofollow target="_blank">Park Dietz, MD, MPH, PhD<sup>2,3,4</sup></a></span> </div> <div class="meta-author"> <a class="meta-author-title is-b stats-meta-author-toggle" data-tog-target=".meta-author-content">Author Affiliations</a> <a class="meta-articleinfo-jumplink section-jump-link scroll-to stats-scroll-to-articleinfo" data-tab-toggle=".tab-nav-full-text" href="#248820753">Article Information</a> <div class="meta-author-content"> <ul class="meta-author-affiliations"> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>1</sup>Norton College of Medicine, SUNY Upstate Medical University, Syracuse, New York</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>2</sup>Threat Assessment Group, Inc, Newport Beach, California</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>3</sup>Park Dietz & Associates, Inc, Newport Beach, California</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>4</sup>UCLA David Geffen School of Medicine, Los Angeles, California</div> </li> </ul> </div> </div> <div class="meta-citation-wrap"> <span class="meta-citation-journal-name">JAMA Psychiatry. </span><span class="meta-citation"> 2023;80(2):186-188. doi:10.1001/jamapsychiatry.2022.4191</span> </div> </div> <div class="widget-EditorsChoice widget-instance-AMA_EditorsChoice_Links"> </div> <div class="widget-LinkedContentToolbar widget-instance-AMA_LinkedContentToolbar"> <div 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data-article-id="2799486"> <div class="full-text-link--text"><span class="full-text-link--text-top">Full </span>Text</div> </a> <div class="abstract-content"> <div class="widget-ArticleFulltext widget-instance-AMA_Article_Abstract_Widget"> <div class="article-full-text" data-userHasAccess="False"> <a class="article-section-id-anchor" id="248820737"></a> <div class="h3 cb section-type-abstract decorated-hed "> <div class="heading-text thm-col sb-sc"> Abstract </div> </div> <p><strong>Importance</strong> <span>Psychiatry has struggled to clarify the types of mental turmoil that are associated with mass violence. While the problem is complex, it may present an opportunity to improve research, as well as inform public dialogue about what types of mental illness are actually associated with such mass tragedies.</span></p><p><strong>Observations</strong> <span>Assuring the diagnostic accuracy of those who commit mass violence is challenging due to the retrospective nature of the analysis and lack of reliable psychiatric data. Psychiatric research has begun to use a dimensional approach that may be well suited to the study of mental illness in perpetrators of mass violence. This approach aggregates psychiatric symptoms into 3 domains of psychopathology: (1) internalizing, (2) externalizing, and (3) psychotic experience. This approach has practical clinical use and research support. A dimensional approach may help clear up misconceptions about the rate of psychosis in mass violence perpetrators, as well as reveal the most common dimensions of mental functioning associated with perpetrators.</span></p><p><strong>Conclusions and Relevance</strong> <span>Improved research methods are needed to clarify and prevent mass violence. More precisely identifying the symptoms and mental turmoil of perpetrators may be associated with improved early identification and prevention. Because adolescence is a critical and formative period in which internalizing and externalizing problems arise, early interventions may have the best chance of reducing future mass violence.</span></p> <div class="movable-ad-target bta"> </div> </div> </div> <div class="widget-ArticleLinks widget-instance-AMA_Abstract_EditorialComments"> </div> <a class="full-text-link is-b d-b bd-none ta-c fl-n radius mt1 mb1 m-auto" data-url="" data-article-id="2799486"> <div class="full-text-link--text fw-b"><span class="full-text-link--text-top">Full </span>Text</div> </a> <div class="seamless-access-button--mobile-only"> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_AdvancedSeamlessAccessButton_Mobile"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> </div> <div class="widget-UserComment widget-instance-AMA_Abstract_UserComment"> <div id="comment-wrapper"> <div class="comment-btn"> <a id="modal-opener" class="btn d-b mb1 sb-background-sc js-modal-opener" href="javascript:;">Comment</a> </div> </div> </div> <div class="widget-UserCommentBody widget-instance-AMA_UserCommentBody_Abstract"> </div> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_abstract_bta_dual"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_abstract_bta_dual" data-params="{"parameters":{"siteName":"jamapsychiatry","siteId":14,"journalId":70,"adDisplay":8,"adSection":"abstract","adPosition":"bta","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div class="widget-RelatedTopics widget-instance-AMA_Related_Topics_Abstract"> <div class="related-topics-block"> <h4 class="related-topics-heading topic-suggestions-heading sb-sc"> Read More About </h4> <div class="related-topics topic-suggestions"> <a href="https://jamanetwork.com/collections/5871/psychiatry-and-behavioral-health" id="item_Link" class="related-topic topic-suggestion no-wrap sb-anchor-light">Psychiatry and Behavioral Health</a> <a href="https://jamanetwork.com/collections/5957/violence" id="item_Link_1" class="related-topic topic-suggestion no-wrap sb-anchor-light">Violence</a> </div> </div> </div> </div> <div class="sidebar"> <div class="branded-bar"></div> <div class="abstract-toolbar"> <a id="pdf-link" href="/journals/jamapsychiatry/articlepdf/2799486/jamapsychiatry_knoll_2022_sc_220005_1675180137.23658.pdf" class="toolbar-tool toolbar-pdf al-link pdfaccess js-pdfaccess" data-article-id="2799486" data-article-url="/journals/jamapsychiatry/articlepdf/2799486/jamapsychiatry_knoll_2022_sc_220005_1675180137.23658.pdf" data-ajax-url="/Content/CheckPdfAccess"><span class="toolbar-pdf-text"><span class="toolbar-link-text-extra">Download </span><span class="toolbar-link-text">PDF</span></span> </a> <a class="toolbar-tool toolbar-full-text is-b" data-url="" data-article-id="2799486"><span class="toolbar-link-text-extra">Full</span> Text</a> <div class="widget-ToolboxGetCitation widget-instance-AMA_Get_Citation_Abstract"> <a class="toolbar-tool toolbar-citation is-b stats-citation" rel="nofollow" data-reveal-id="get-citation" data-reveal> <span class="toolbar-link-text">Cite</span> <span class="toolbar-link-text-extra">This</span> </a> <div id="get-citation" class="reveal-modal get-citation" data-reveal> <h3 class="get-citation-title">Citation</h3> <p class="get-citation-citation">Knoll J<span class='al-author-delim'>, </span>Dietz P. 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Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning | Psychiatry and Behavioral Health | JAMA Psychiatry | JAMA Network