Hi there, the thing about prodromal paranoid schizophrenia is that the prodrome can go on for a very long time without any psychotic symptoms. I'm not suggesting the guy was psychotic or that he met criteria for schizophrenia. Prodromals don't. That's the point. They don't have schizophrenia yet. It's not a formal diagnosis, but it's a well-known condition. I really love your blog!

Along with the Prodrome page, be sure to read more of this person's writings, linked up at the bottom of the page such as this resource page discussing Schizophrenia, listing many websites.

On what basis are you not convinced the "guy" is clinically psychotic? I think his behavior screams psychosis frankly. I also think flat affect is very consistent with a diagnosis of schizophrenia -- "negative" symptoms of schizophrenia vs. "postive" symptoms. Professionals are always saying the "negative" symptoms are much harder to treat than the "positive" ones. I would like to qualify all this by saying I don't buy into the diagnosis of schizophrenia period. It's just a fancy word for psychosis in my book. It covers such a broad range of different clusters of symptoms reflecting psychosis that it means very little -- to me anyway. I also hope to comment at length at some point about why I believe 16 months of psych treatment (from December 2005 when he was involuntarily hospitallized over night) were undoubtedly driving this guy mad. I really do not believe any troubled person who is NOT medicated would ever act out to this extent and the parallels with Eric Harris who was driven mad, first on Zoloft and then Luvox, right down to the videos and pages of suicide notes is unbelievable.

P.S. Regarding the drycleaning theory (and of course the cat poop theory) I have also heard a theory that children born within 18 months of an older sibling are at much higher risk of "schizophrenia" (i.e. psychosis) and Cho has a sister who is probably 24 and went to Princeton. Cho was 23. I'm wondering what issues he might have had with having a super high achieving sister and how that played out in his family.

because i am interested in waiting for all the facts to be in sara. a few video clips and deranged statements aren't enough to dx anyone upon, so until we get more clarity i am sticking with we don't know.

I don't believe he was psychotic. Isn't it interesting that when he went to purchase the gun he didn't sign his name Question Mark? I bet he wasn't silent when he was asked questions for the background check, either. This guy was completely in control of what he was doing. Look at the planning that went into this - the chains on the door to keep people trapped in there, the purchase of the guns & ammunition in preparation for his rampage... I don't think we're ever going to find an explanation for how this creep could be so cruel, any more than we can explain what turned Jeffrey Dahmer into the person he became.

great points Lisa. in the wake of such tragedy, we all clamor for tangible, ordered explanations. they are rarely there.

driving home the other night i was listening to loveline. the doctor was complaining about how all of these sorts of tragedies are preventable, but currently "clinicians aren't empowered to stop these kinds of people and treat them. they are all treatable." as a once-patient, i find that sentiment incredibly naive.

There is simply no psychosis here whatsoever, period. I can't see any. Yeah, he's got a flat affect, sure. What else? I don't see anything. I don't really see any thought disorder either. As the commenter above pointed out, I'm sure he talked well when he went to buy the guns. I don't see any delusions here either. Want to point his delusions out to me? Where are they?

Anyway, usually diagnosis of psychosis means something delusions and or hallucinations, neither of which are present here.

I guess it depends on how we define psychotic. It is true we don't know what he was thinking when he was killing all those people but I guess I think anyone who is killing 32 people is psychotic. And just because he exhibited some so called planned actions and knew who he was doesn't mean he wasn't psychotic -- please. Would people like to define what they think psychotic is then?

For being considered non-verbal, silent, etc. even w/reports coming in from his family--he sure as hell gave a damn well-spoken manifesto on camera didn't he?
Also, not one of us will ever know if voices were in his head, driving him or "telling" him to do what he did. Though he may not appear more than flat affect to some; one cannot know what really motivated him; and voices DO motivate psychotic people. Not all people w/psychosis are completely shut down and incapable of functioning. psychotic and smart can be a dangerous combination.
Sara, regarding your comment about age apart from an older sibling: my daughter is 19 months younger than her double-major w/honors college age sister.
One social worker actually told me she believed my daughter felt she could not hold a candle to her older sisters, and that her psychosis at the time was her way of gaining attention.

Imagine the input I have received from 1/2 dozen psychs, 20 staff minimum X 4 hospitals, several case managers--ALL with their own theories and ideas. The commentary never matched from one group to the next, and either did the file information sent to one another.

Im not quite clear on one aspect of this shooter Cho--was he involuntarily committed or not? because in the state of WA. once that happens, a person cannot purchase, or keep their gun, or permit unless a mental health judge reverses it in court.

Robert,
Are you basing lack of seeing delusions from the video clips? or did you observe this person for 18 months in real life?

I cannot believe anyone can claim to see or not see delusions based on a couple of video clips that most likely were created in a delusional, fantasy world.

Ive lived with a psychotic/delusional person for too long to say that on the exterior, all can appear well, and in fact it is not internal stimuli can present itself differently in outward appearance, and often psychotic people are lucid enough to answer doctors and appropriate people [like staff in hosptials]to convince all they are well. Its called working the system.

I do not see any evidence at all of any active psychosis in this individual. We don't have any evidence either from any of the news reports, nor could I see any evidence from the videotape, in which he actually appeared quite sane. He blames others for his problems, for being miserable. People were mean to him, people were not nice to him, so he's gonna kill people. He hates everyone, and they all done him wrong. He's out for paybacks. That's the mindset of the Columbine killers, NEITHER of whom were psychotic! None of these damn school shooters were psychotic to my knowledge; they were just mad! Show me the psychosis in his videotape. Being paranoid and blaming society for your misery and hating everyone are not delusions and is not evidence of psychosis. It's not healthy, but that's another matter. To prove psychosis we must prove delusions - were fellow students slowly poisoning him, messing with his electronic devices, plotting with the aliens to kill him, working for the CIA to do him in, messing with his brain waves? Get it folks? THAT is psychotic thinking - THOSE are schizophrenic delusions. See any of that in the video? Show me.

I think that someone off into full-blown paranoid schizophrenia would have had a hard time pulling this thing off the way he did - with such elaborate, meticulous, even brilliant planning and forethought. Most of the psychotic people I have known could barely organize a trip to the bathroom!

Nope you sure as Hell do not have to be psychotic to kill 32 people, no way. People do it all the time in Iraq. Are they psychotic too. You just have to be really angry and coldblooded.

Stephany - you say prove non-psychosis - sorry, no go - can't prove a negative. I'll throw it back to you - YOU prove he WAS psychotic. Your move.

I don't think this guy had ever been psychotic yet - I think he was just starting to move towards that area and in the future, I think he would have gone full-blown psychotic. But I don't see it yet. Looks like prodromal schizophrenia - the weird behavior, the mutism, the depression, the fire-setting, bomb threats, stalking, esp the fantasy girlfriend - that's all possible in the prodrome of schiz.

I admit to being astonished that anyone could NOT view Cho's behavior as psychotic and comparing him to someone fighting in a war environment such as Iraq doesn't convince me. Please give me your definition of psychotic. Remember I am not labeling him with anything from the DSM -- just calling his behavior psychotic. And psychotic does not mean being out of control. I got my Abnormal Psych textbook out and this is how psychosis is definied: "Psychosis is a condition characterized by loss of contact with reality. Often sufferers' capacity to perceive, process, and respond to environmental stimuli becomes so impaired and distorted that they may be unable to achieve even marginal adaptive functioning. Individuals in a state of pyschosis may have hallucinations (false sensory perceptions) or delusions (false beliefs), or they may withdraw into a private world." This certainly sounds like Cho to me on the basis of his actions, his writings, his videos and the testimonials of people who were acquainted with him. In the interest of a debate that moves us forward please post your definitions of psychosis.

Regarding the birth interval, I only said that it INCREASED the risk, not that it determined a risk for everyone. Of course not every person born within 18 months of a sibling is schizophrenic or psychotic. And of course there have to be many other factors at play to drive someone to this point. I still believe that not acknowledging any role of medication in all this is a mistake -- it's one thing that really could have been done differently. There is simply no doubt in my mind that medication can facilitate and exacerbate this process of going mad and that the failure to investigate this and understand this process means these deaths will continue unabated and only get worse. There are over 24 school and workplace shootings on ssristories.com in which the perpetrator was on medication. In fact this includes almost all the notorious rampage shootings that have occurred in the last 20 years since Prozac came on the market and in cases that are not listed, perhaps like Kyle Huff's, it simply isn't known whether they were or not. Of course I am NOT saying it's the only factor but I am saying that there is some probability that this incident would not have occurred without the medication -- it is a necessary, but not sufficient cause. Until people can really wrap their heads around this idea we are going to be in big trouble. I really believe that.

I am not claiming he WAS psychotic. I am discussing the inability to see the person's psychosis/thoughts/delusions based on a small video clip.
I have a child who DID think the water was poisoned, among many other classic delusions and mixed in w/visual hallucinations, [and in care of a psychiatrist]. Carefully observing her inpatient as well as outpatient for months, and nearly a year last year[inpatient]not just from a video clip.
There were many times she was lucid enough to have been observed [for example] via a video clip during this time of complete psychosis, and you never would have been able to know her thoughts were over the top, and being driven by voices in her mind.

I have a unique perspective, having lived with someone for 8 years exhibiting true psychosis,and visual hallucinations, as well as being inside several adult psych wards and observing others as well.

You may want to look into medication induced behaviors from medications such as Luvox, Zoloft, Zyprexa and others. The Columbine shooter was on the same med mix that was given to my daughter at age 11, just months after Luvox was removed from the market due to Columbine, and re-entered the market just in time for a psych to rx it to her, and she became a completely different person as a result.
Once all medications were removed she suffered what I believe as do others; withdrawal psychosis.
This is an interesting discussion, and I will leave my thoughts at that.

btw robert,

I have been researching the Prodrome for 4 years. Prodrome In the last 2 solid years, my daughter has seen 6 psychiatrists; several prominent Chief of Staff; inpatient, with exclusive teams in one world known hospital for example. Not one of these psychiatrists discussed the Prodrome, and several did not believe in it, when I brought it into the discussion.
When I started researching it 4 years ago, one psychiatrist asked me what Prodrome was...many times my discussions were over the top of the typical psychiatrist's box of thinking.

I understand the Prodrome, and your reasoning behind it; but I do agree to disagree about dx'ing a person based on a short video observation that is now giving a step-off point to "could have been Prodrome, but we will never know if schizo."
Have a nice day.

A psychotic person has delusions and or hallucinations and does not recognize that they are ill. They experience loss of reality and loss of insight. Weird behavior alone is typically not enough to give a psychotic dx. Just because someone acts really weird does not mean they are psychotic. Did Cho have delusions or even hallucinations that we did not know about? Maybe, but I kind of doubt it. Once schizophrenics start hallucinating a lot, they are usually really out of it. Furthermore, we should have seen some evidence of delusions somewhere, in the writings or in the video. It's not really a good theory to say "Maybe he had hidden delusions or hallucinations". It's non-falsifiable.

I don't care if psychiatrists say they don't believe in the prodrome. We know it exists, and if you read the DSM casebook you can see some good definitions of it. And I've seen a case myself with a prodrome of seven years before onset of serious auditory hallucinations. I'm not diagnosing prodrome based on a video. I'm diagnosing it based on his whole deteriorating and increasingly strange and violent behavior, plus his depression, in the absence of obvious psychosis, plus what looks like he is starting to move towards psychosis around the shooting.

A lot of people with OCD are really out of it and strange, but they don't have delusions, they have obsessions. And many of those obsessions look like psychotic delusions. You really need to be careful diagnosing psychosis. It's not fair to throw that label around.

As far as your daughter goes, sure maybe she seems lucid based on one video. Ray might have too. But we have more than one video with Cho. We have people who have known him for a long time and no one is reporting any evidence of delusions or hallucinations whatsoever.

The evaluating doc at the hospital said no thought disorder or evidence of psychosis. He displayed no thought disorder when he went to buy the gun. The videos and plays, while strange, do not display typical thought disorder either.

And why is it NOT appropriate to compare him to mass killers in Iraq. They kill people every day, lots of people, even lots more than 32 people, at a time. Why is Cho psychotic for killing 32 people, and the jihadis in Iraq not psychotic for killing 32 innocent civilians, just because they are Shia or whatever.

Why is it non-psychosis because there is a war on and they hate the Shia but psychosis if there is no war on and he hates people in general? You're still killing innocent people for no reason other than hate.

Robert,
It would be interesting to know if you have a medical, or mental health background? Clinical research? or reporting?

I find this to be quite an alarming interview you did. Interview with a woman with history of suicide attempts and self-Harm.

"A: I'm also a cutter. I cut myself.

RL: Oh you are one of those. Ok. We used to have some of those down at the coffee shop, mostly this one woman. A couple of them formed some kind of a sick club called [town name] Cutters. I wanted to punch her in the face! I mean, you should not take pride your pathology!"

Just curious how you had problems with her diagnosis, and what you based all of your theories on? interviewing people, or having a medical professional background? You question her bipolar dx, stating that you think it's depression. Honestly can't understand why she kept the interview going, when you called her "one of them", and expressed wanting to punch someone in the face for "taking pride" in their "pathology".

Nope, I'm actually a "consumer" just like so many of you. I have OCD and I have been diagnosed with it more times than I can count. I don't have any other dx's, but that one is bad enough.

I'm no clinician, but the ones I have talked to say I know an awful lot about the field. As a non-clinician, my opinion has to be taken with a grain of salt.

She was very nice during the entire interview. There was no hostility or annoyance or irritability at all from her. She strongly agreed with me that people should take pride in their pathology, especially being a cutter. Taking pride in being ill is preposterous. Ill is ill. You try to get better, you don't just sit there and be as sick as you can be and cheer about how wonderful it is! BS!

She lived next door to me for months and I saw her many times and she never appeared manic. All of my siblings and my father are bipolar. I've been living with this illness in my face for 25 years now. I know it like the back of my hand.

She told me she had a bipolar dx and I started describing my brother's manic symptoms and she kept looking at me funny. She described her "manic" symptoms and they didn't really sound manic at all to me. Just sounded like she was pure depressed, if anything.

The problem with the people on here is this is the "We're not ill, don't treat us!" crowd. We hate psychiatry! Fine, be that way, see how far it gets you. See how many bipolars, chronic depressives, schizophrenics, etc. just up and recover on their own. Personally, I take meds. I've been on SSRI's for 14 yrs. I can't make it without em.

One more thing. Cutters are sick! Period!

Thanks for the clarification Robert, and the additional information regarding that interview, now it makes a bit more sense to me.
Some people are successful off of medications, and some post here about their experiences on and off of medications.
As far as your comment about "cutters are sick, period"--well I have a recovered cutter who is now properly dx bipolar, hasn't cut in one year since being properly medicated, and in DBT group and therapy.
Yes, someone who cuts may have an underlying illness. Did you offer your friend advice to seek treatment? Lithium helps people who cut; and Lamictal stabilized my daughter. [i have more than one kid].
Interesting discussion.

She told me that she had not cut in 2 years. We also discussed her suicide attempts. I guess she doesn't really need treatment right now; she claims she's not suicidal or cutting anymore. The women at the coffee shop formed a damned club called [town name] Cutters. Sick! That's what made me angry. Yeah, I did feel like smacking her for saying that.

I just can't understand self-harm. OTOH, they say I have OCD and I think I've got a pretty weird stare in my eyes, and people often treat me like there's something wrong with me, so I guess I've got my own problems. Other than the distracted stare of the obsessive, I think I act pretty normal, but it doesn't take much for people to treat you like there is something horribly wrong with you.

Robert, I don't know many bipolars, chronic depressives, schizophrenics who just up and recover on their own, either. Those who are better, I guess, found what works for them. All I know is that I'm better off medication than on. I don't have the answer for other people. I don't even have the answer for myself. I do know what can lead me into trouble, and I try to avoid those things.

I think there's this tendency, and I'm very guilty of it too, to take our own experience and generalize to everyone else. I see it on other message boards also. There's this view that if a person is truly suffering from a serious mental illness then they would HAVE to take medication to get better. Well, I don't know if that's true. During the period I was on my cocktail of 4 psych medications things were so bad that the dog would shit in the floor and I didn't clean it up for weeks. I just walked around it. That's how bad it was. That's what landed me in the psych hospital the 3rd time. Some would say, well they just didn't find the right cocktail for me, yet. I would say that it was the cocktail that led me deeper into depression. I took myself off all the medication and slowly clawed my way back up to the surface. I definitely have not done it on my own. And I'm not cured, or fixed, or perfect...I'm just better.

I don't remember anyone on this board saying "go off your medications." What some people are doing, is as Stephany said, sharing their own experiences. I think we can all learn something from each other.

Well, if you are depressed and better off all your meds, all the power to you. I don't recommend it for manics or schizophrenics though. And a lot of depressives feel that nothing works for them and then they get on a drug and it's the only thing that lifts them out of it.

I am extremely wary of psychs who are always trying to put me on high dose SSRI (I won't take them). The latest was to add Seroquel up to 300 mg! For OCD! I read up on the net and said forget it. OTOH, 12.5 mg Seroquel knocked me out hard and I may just want to go on that for sleep.

The psychs are insane with their lunatic drug cocktails and whatnot. It's just bonkers. The drugs are awful but so are the illnesses. It's a really tough call.

I've also had psychs misdiagnose me as psychotic (not true - just OCD) and a couple of guys even wrote schizophrenia and paranoid schizophrenia. I'm not happy about that at all.

"One more thing. Cutters are sick! Period!"

Isn't there some rule on this blog about not deriding anyone else's illness? Seriously, I don't won't to run a censorship line, but comments like that are just plain bigoted. Period.