People with autism are less likely to commit crimes. Identifying individuals at risk for psychotic breaks, though, may be the one appropriate focus of the mental health discussion raised around Adam Lanza.
Given the unspeakable events last week in Newtown, everyone is searching for answers about what might have driven Adam Lanza to kill. Attention has focused on his possible autism spectrum diagnosis, but as researchers and advocates have pointed out, autistic people are actually less likely to commit crimes compared to those without the condition.
There is, however, another disorder that can both be linked with planned violence and mistaken for autism, which may account for part of what went wrong, in this instance or others. That's psychosis, which can occur as part of schizophrenia or in some cases of severe depression or drug misuse. While it's important to understand the differences between autism and psychosis, it's also critical to know that stigmatizing, bullying, rejecting, and isolating people who are different exacerbates every mental illness and developmental disability ever studied.
One of my colleagues, Dr. Bruce Perry, is senior fellow at the Child Trauma Academy and a child psychiatrist who has worked with or consulted on cases involving both children exposed to extreme violence and young perpetrators. He consulted with authorities guiding the response to Columbine.
To be clear, no one can diagnose a patient from afar, and there are too many unknowns in this case to diagnose Lanza. Still, for academic purposes and to the point of accurate mental health discussion and addressing ideas about identifying at-risk individuals, Perry says of the shooter: "My first thought was that he might have had a psychotic break -- and that his odd, disengaged behaviors earlier in life -- reasonably labeled as something like an ASD by some -- might actually have been prodromal psychotic disorder."
Schizophrenia is often not diagnosed until a first psychotic episode occurs, typically in the late teens or early 20s. These episodes are marked by delusions, hallucinations (mainly auditory), and often extreme paranoia. But long before these occur, some children who ultimately develop the disorder seem "off" and retreat from social contact. This is part of a set of symptoms known as a "prodrome" because it precedes those that characterize the later illness.
Like autism, schizophrenia is now believed to be a condition involving differences in early brain development, which probably begin in the womb, even though symptoms may not appear until years or even decades later. Lanza was 20, which is right in the typical range for a first psychotic episode to occur. But that is the most we can say.
Early symptoms of schizophrenia can sometimes be indistinguishable from those of autism: they include social withdrawal; communication problems and restricted speech; odd, repetitive behavior; an apparent lack of emotion or emotional expression and often, lack of conformity in terms of hygiene and dress. In both cases, the symptoms can start in early childhood, though with schizophrenia, there is often a noticeable exacerbation of prodromal symptoms in the year or two before the first psychotic episode.
Both conditions are also sometimes linked with extremely high intelligence, which makes our failure to provide effective help even more wasteful. Lanza was an honors student, whom some of his classmates labeled a "genius." He was known to dress formally and carry a briefcase, not the backpacks favored by most schoolchildren. In some instances then, because we don't have biological markers to provide a definitive diagnosis, it may be impossible to tell if someone has an ASD or is going to develop schizophrenia until psychosis itself occurs.
Indeed, some of the same genes that have been linked to autism risk are also linked to schizophrenia risk -- and some of the same environmental triggers also raise risk for both. For example, having an older father or being in the womb while your mother suffers from certain infections elevate both the risk of autism and schizophrenia. It is not known why the predisposition becomes one disorder rather than the other.
Says Perry, "Certainly from what little we know about these kinds of spree events involving children, there are often intrusive, recurring psychotic ideations [in the perpetrators], such as seen in psychotic breaks such as the Aurora shooter or in a severe depression with psychotic features such as with Andrea Yates. [These] help drive the behavior."
Acute psychosis is linked with an increased risk of violence, which is at least doubled in schizophrenia compared to that seen in normal people and arises in other disorders involving paranoid fears and delusions. This risk is even higher for people with schizophrenia who have alcoholism or addiction: their risk of violence is nine times higher. A 2011 review of the research found that 35 percent of people with a first episode of psychosis have committed some type violence, but only 1 percent of this group engaged in violence serious enough to result in hospitalization or death.
That said, people with schizophrenia in treatment taking appropriate medication are no more likely to be violent than anyone else and only 5 to 10 percent of all murders are committed by people with any type of mental illness.
It's important here, too, to distinguish between psychosis -- which involves delusions, hallucinations, and loss of contact with reality -- and psychopathy, which involves predatory, self-centered and violent behavior and complete lack of concern for the feelings of others. Psychopathy is the extreme form of antisocial personality disorder and is, not surprisingly, the diagnosis linked to the most extreme crimes, like serial killing. Neither autism nor schizophrenia is linked with psychopathy.
And as for autism -- if it ultimately turns out to be what Lanza had -- that diagnosis is actually linked with reduced crime risk. People with autism tend to be extremely conscientious, often strictly following moral rules in ways that cause social problems; for example, by avoiding white lies. "From what we do know about ASD, [the shootings] would be pretty atypical," says Perry. "There's no risk in the diagnosis itself," agrees Dr. Harold Bursztajn, co-founder of the Program in Psychiatry and the Law at Harvard Medical School, who has reviewed the research.
In some cases, however, Bursztajn notes, "There is a risk that people who are impaired in social functioning -- who have a difficult time communicating, who become isolated-- can at times respond impulsively and at other times hold grudges forever and be hypersensitive and never able to get over a slight. They can become depressed, psychotic and delusional. So what we're looking at is not a risk associated with a diagnosis, but a risk associated with an impairment." That impairment is not inherent to autism, but can come from the isolation that stigma and lack of appropriate services creates.