When Psychiatry Fails

After Adam Lanza gunned down twenty children and six teachers at Sandy Hook Elementary School, the governor of Connecticut charged the Office of the Child Advocate to try to find out what went wrong.

How did it happen that no one had seen it coming? How did it happen that no one had found a way to treat Lanza?

According to Reuters, the report will conclude:

The extent of Newtown school shooter Adam Lanza's growing rage, isolation and delusions when he was a teenager were apparently overlooked by his mother, psychiatrists and counselors, according to a report expected to be issued next month.

The report found that Lanza, who gunned down 20 children and six educators at the Sandy Hook Elementary School nearly two years ago, did not have to become a violent adult, Scott Jackson, chairman of the Sandy Hook Advisory Commission, said on Friday.

It says better screening and evaluation might have helped detect earlier the 20-year-old's potential for violence. Lanza also killed his mother and then himself in the Dec. 14, 2012 violence.

Of course, when faced with a horror like what Lanza did at Sandy Hook, it is normal to ask what went wrong. And yet, Lanza’s problems were not ignored by his mother or his father. Unfortunately for them and for the people of Sandy Hook, they were doing what the psychiatrists told them.

The failure ought not to be laid at the foot of the parents, but of the psychiatrists who had examined and evaluated Lanza.

For those who prefer not to wait for the Connecticut report Andrew Solomon wrote his own extensive analysis of the situation for The New Yorker several months ago. See also, my previous post.

Solomon discovered that Lanza’s parents had taken him to see many psychiatrists. Surely, we cannot fault the parents for trusting the opinions of major psychiatrists in New York and New Haven. It may not seem possible that they were all wrong, but clearly they were.

They were wrong when they placed Adam on the autism spectrum, diagnosing Asperger’s syndrome.

Solomon reports:

When Adam was thirteen, Peter and Nancy took him to Paul J. Fox, a psychiatrist, who gave a diagnosis of Asperger’s syndrome (a category that the American Psychiatric Association has since subsumed into the broader diagnosis of autism spectrum disorder). Peter and Nancy finally knew what they were up against. “It was communicated as ‘Adam, this is good news. This is why you feel this way, and now we can do something about it,’ ” Peter recalled.

A year later, they took Adam to see another psychiatrist:

When Adam was fourteen, shortly after Ryan had left for college, Peter and Nancy took him to Yale’s Child Study Center for further diagnosis. The psychiatrist who assessed Adam, Robert King, recorded that he was a “pale, gaunt, awkward young adolescent standing rigidly with downcast gaze and declining to shake hands.” He also noted that Adam “had relatively little spontaneous speech but responded in a flat tone with little inflection and almost mechanical prosody.” Many people with autism speak in a flat tone, and avoiding eye contact is common, too, because trying to interpret sounds and faces at the same time is overwhelming. Open-ended questions can also be intolerable to people with autism, and, when King asked Adam to make three wishes, he wished “that whatever was granting the wishes would not exist.”

Dr. King added a diagnosis of obsessive-compulsive disorder:

King noted evidence of obsessive-compulsive disorder, which often accompanies autism. Adam refused to touch metal objects such as doorknobs and didn’t like his mother to touch them, either, because he feared contamination. “Adam imposes many strictures, which are increasingly onerous for mother,” King wrote. “He disapproves if mother leans on anything in the house because it is ‘improper.’ . . . He is also intolerant if mother brushes by his chair and objected to her new high heel boots, because they were ‘too loud.’ . . . If mother walks in front of him in the kitchen, he would insist she redo it.” King was concerned that Adam’s parents seemed to worry primarily about his schooling, and said that it was more urgent to address “how to accommodate Adam’s severe social disabilities in a way that would permit him to be around peers.” King saw “significant risk to Adam in creating, even with the best of intentions, a prosthetic environment which spares him having to encounter other students or to work to overcome his social difficulties.” And he concluded that Nancy was “almost becoming a prisoner in her own house.”

Lanza was also being treated at Yale by nurse Kathleen Koenig. His psychiatrist had put him on Lexapro, an anti-depressant, but he reacted badly to it.

Solomon writes:

Adam stopped taking Lexapro and never took psychotropics again, which worried Koenig. She wrote, “While Adam likes to believe that he’s completely logical, in fact, he’s not at all, and I’ve called him on it.” She said he had a biological disorder and needed medication. “I told him he’s living in a box right now, and the box will only get smaller over time if he doesn’t get some treatment.”

Perhaps this tells us that depression was not the problem. It also makes us ask why no one had noticed the signs of psychosis or had tried an anti-psychotic medication.

As for Adam’s refusal to take any other medication, this is yet another reason to loosen the laws about involuntary commitment.

In any event, the Lanza parents accepted the Asperger’s diagnosis. To their and the community’s regret. Later, Adam’s father, Peter Lanza had a better sense of the problem:

Peter gets annoyed when people speculate that Asperger’s was the cause of Adam’s rampage. “Asperger’s makes people unusual, but it doesn’t make people like this,” he said, and expressed the view that the condition “veiled a contaminant” that was not Asperger’s: “I was thinking it could mask schizophrenia.” Violence by autistic people is more commonly reactive than planned—triggered, for example, by an invasion of personal space. Studies of people with autism who have committed crimes suggest that at least half also suffer from an additional condition—from psychosis, in about twenty-five per cent of cases. Some researchers believe that a marked increase in the intensity of an autistic person’s preoccupations can be a warning sign, especially if those preoccupations have a sinister aspect. Forensic records of Adam’s online activity show that, in his late teens, he developed a preoccupation with mass murder. But there was never a warning sign; his obsession was discussed only pseudonymously with others online.

True enough, no one can predict what now appears to have been a psychosis will manifest itself. Certainly, it need not produce mass murder.

And yet, the question remains: why?

Solomon asked it:

But, important as those issues are, our impulse to grasp for reasons comes, arguably, from a more basic need—to make sense of what seems senseless. When the Connecticut state’s attorney issued a report, in December, CNN announced, “Sandy Hook killer Adam Lanza took motive to his grave.” ATimes headline ran “CHILLING LOOK AT NEWTOWN KILLER, BUT NO ‘WHY.’ ” Yet no “motive” can mitigate the horror of a bloodbath involving children. Had we found out—which we did not—that Adam had schizophrenia, or had been a pedophile or a victim of childhood abuse, we still wouldn’t know why he acted as he did.

In the most obvious sense, knowing why Adam Lanza did what he did is far less important than stopping him from doing it. That would have entailed a correct diagnosis and treatment, probably in an inpatient facility. Knowing how troubled he was is not the same as knowing why did what he did.

If we still want to know why he did it, we might also consider the possibility that the intense media attention to mass murderers like the Aurora shooter James Holmes and Columbine killers Eric Harris and Dylan Klebold showed Adam Lanza a way to become infamous.