April 20, 2007 -- Dr. Welner, an associate professor of psychiatry at NYU School of Medicine and has been the lead examiner on some of the most complex and sensitive cases of recent years, including a number of mass shootings. He appeared on "Good Morning America" to discuss the need to bring give paranoia the clinical attention it needs, and added to those remarks for ABC News.
The mental health field has been very successful in taking the stigma out of many conditions like depression, anxiety and post-traumatic stress disorder. But schizophrenia remains a term that inspires fear in many and shame in families, including the patients themselves, and the avoidance is part of a long-standing problem that needs to change.
Schizophrenia is a condition that affects the rationality of thoughts, emotions, communication, relatedness to others and interpretation of the environment.
Schizophrenics' perspectives are often distancing, and their faces expressionless. It is easy to experience them as unfeeling, or cold, because their outward appearance reflects differently. A schizophrenic's emotional tone may include hostility, which can be intense.
To some afflicted more severely, that may mean hearing things that others don't hear, or even seeing things that others don't see. To make matters worse, those voices are typically disparaging, often profane and commenting on someone in the third person. Imagine having to navigate through your day through a jangle of voices saying, "You're a loser," "Shut the ---- up," or "You should lose weight, everyone thinks you're a lard." Such a tragic burden, such a distraction.
Even for those who don't have hallucinations, schizophrenia is a tough condition to carry. A schizophrenic has difficulty with the correct frequency of communication, interpersonal skills, efficiency, new information and complex demands. Unfamiliar circumstances separate those with this condition in ways similar to the autistic. They have difficulty relating to others, and others have difficulty relating to them.
Furthermore, the person with schizophrenia labors under an uncertainty of who he is, his place in the world, what he aligns with. That fragility affects sex orientation, religion and future pursuits.
People with schizophrenia -- and others with paranoid disorders -- use defense mechanisms just like the rest of us. Their limitations, however, affect the defenses they use. Schizophrenics' defenses may be irrational displays of anger and hostility, or irrational ideas of persecution or grandiosity. Thinking may be replete with the most peculiar preoccupations of death, sex and religion.
Paranoid schizophrenia is a subtype of schizophrenia in which persecutory thinking or ideas that others refer to you or mean you harm are prominent. Those with paranoid schizophrenia often function at a "higher" level that those with other subtypes, but they are still notorious for intense hostility and for being quick to suspicion, prickly and highly defensive. They differ from those with merely suspicious personalities by having frankly bizarre aspects to their behavior, speech, appearance and or/manner.
Now imagine having that kind of condition and reading -- or being told -- that you just have to live with it because it is incurable.
Is it any wonder that those who might be told they have schizophrenia, especially in their late teens to early 20s, might refuse dealing with mental health professionals in order to refuse dealing with the illness?
The medical problem worsens: The person's guardedness and suspiciousness and associated chemical imbalance worsens and exerts second-generation effects on the brain.
The social problem worsens: The person's suspiciousness distances him from others. The person's hostility distances others.
The interpersonal problem worsens: The person's emotions become that much more frayed, and his disconnectedness and helplessness contribute to increasing frustration, anger and lashing out at others.
The functional toll worsens as each of these symptoms mount in significance and interfere with everyday life.
Awareness of that toll has left many, and for many years, feeling helpless to intervene. They, in turn, may drift away from the schizophrenic who leaves them feeling rejected, offended, insulted, creepy and in some instances, frightened.
None of this happens overnight. The earliest stages of schizophrenia are a progressive slide. Even doctors may have difficulty recognizing what is happening in the beginning -- in part because patients are too guarded to tell them. Or, when patients who have already seen doctors fear being tranquilized or told of the chronic nature of their condition, the patient simply does not disclose history.
In my experience, doctors are almost as afraid to tell patients that they have schizophrenia, in the early stages, as patients are to accept such a diagnosis. But treatments for this condition have increasingly been refined in recent years. If schizophrenia carries with it a stigma comparable to HIV, perhaps, like with that virus, better awareness of more creative solutions can help patients. Patients may come to see schizophrenia as more akin to insulin-dependent diabetes.
Seung-hui Cho was progressively more peculiar in his speech, expression and manner. His writings were replete with sexual and nihilistic obsessions. He was guarded, very hostile and provocative, and exhibited very constricted expression. While depression may have affected him, it is hard for me as a forensic psychiatrist to consider any alternative to schizophrenia as a diagnosis.
We do not yet know enough to say whether the Virginia Tech shooter killed because of his illness. Mass shooters, as we've talked about on these pages, are the product of disappointed expectations of entitlement and a sad outcome when blaming others turns to contempt and dehumanization. Such killers choose a quest for immortality very much linked to a fascination with guns and the power they bestow, and the potential for such destruction to redefine them through the lore of sensational crime in a celebrity culture. That has nothing to do with schizophrenia.
That said, Cho's history is a familiar one to many of my colleagues -- a man struggling, too hostile to others to coax into treatment, too nonviolent in the past to force treatment upon, too guarded in the substance of his fantasy and whom he identifies with and too fragmented to connect easily with others.
We are not above solving the mysteries of the forbidding. Look at the marvelous keys that are unlocking autism these days. It's time to talk straight about schizophrenia and take away its stigma. When we are better able to teach each other about the condition and the treatments for it, we will teach the falling to recognize their descent, that we might catch at least some of them.
Dr. Welner is chairman of The Forensic Panel, a national forensic science practice. An associate professor of psychiatry at New York University School of Medicine and adjunct professor of law at Duquesne University School of Law, he is developing an evidence-based test called the Depravity Scale, http://depravityscale.org, which invites Americans to participate in surveys that are used to form a standard of what represents the worst of crimes.