What the Pittsburgh Synagogue Shooter Trial Tells Us About Psychiatry

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Today, the third and last phase of the Pittsburgh trial begins. Last Thursday, the jury quickly decided that it can move forward to consider the death penalty.

Diagnostic Expertise

So far, the main witnesses have been psychiatrists and other related medical specialists. As usual, experts that were chosen by either side gave different options about the perpetrator’s mental health and how that may have influenced his crime. Much focused on whether a given psychiatric diagnosis included delusional thinking, which could have impaired his “intent.”

All combined, several diagnoses were presented:

-Schizophrenia

-Schizoid personality disorder

-Epilepsy

-Adjustment disorder

In addition, sub threshold symptoms and a history of other disorders became apparent: major trauma, substance abuse, and clinical depression, among them. The depth of any treatment was not apparent to me.

While someone could conclude from these diverse opinions that those in clinical psychiatry are not reliable enough in our assessment ability, they would fail to understand the difference between evaluating an individual patient for treatment versus a forensic evaluation for the purpose of answering questions by the prosecution or defense.

The Role of Cults and Cultish Thinking

Besides the individual assessment of the accused, and any contribution of his personal history, the case also focused on his most recent preoccupation, which was online anti-Semitism conspiracy theories, specifically about one of the synagogues he attacked bringing in immigrants to replace white individuals.

Discussion ensued about whether all his beliefs were just like those of others online that he viewed over and over, or that he had his own unique delusional disease. Nothing I found, however, discusses these online tropes as being parts of cults or cultish influence. Cults have never been a prominent focus for psychiatrists, but there is one diagnosis that was never brought up that could reflect cultish thinking: “Other specific Dissociative Disorder, 300.15.”

Resolving a Dialectic

One resolution of the differing testimonies might lie in a more complex interaction and causation of both the individual and the social. Perhaps the perpetrator had psychiatric dysfunction that made him uniquely vulnerable to undue influence, but that dysfunction did not reach the DSM diagnostic level. The undue influence would lie in the social anti-Semitic conspiracy theories which he believed—and still does—were true, and that his mass shooting would make him a hero like our country’s Founding fathers.

Serendipitously, perhaps, a new book on delusions came out last Wednesday that may help our understanding.¹ Right from the beginning of the book, the question of how to define delusions is conveyed. On page 3, the DSM-5-TR definition is quoted:

“Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.”

The confusion from this definition in regard to the perpetrator is that his subculture affirmed his conspiracy theories, but most of the general public apparently did not.

Alternatively, in the Preface, there is this current caution:

“Importantly, it is established that delusional beliefs cannot be distinguished from popular unsupported beliefs on the basis of their content alone: rather, one must consider the role of social factors in acquiring and potentially spreading the belief.”

Certainly, anti-Semitism conspiracy theories spread to the perpetrator.

Right after the verdict of eligibility for the death penalty, a community leader, exclaimed:

“It is clear that this is hatred of Jews. This is anti-Semitism. This is not a mental health issue.”

I continue to wonder whether hatred is a mental health issue, however. What else is it when it is an inappropriate individual or collective psychologically-based response to a group of others? No, that does not necessarily usually fit an official DSM-5 disorder, but it would fit being a social psychopathology if only we had such a classification. As we will continue to discuss, there are treatments and interventions that can address these social psychopathologies if only we use them.

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.

Reference

1. Hardy K, Turkington D, eds. Decoding Delusions: A Clinician's Guide to Working With Delusions and Other Extreme Beliefs. American Psychiatric Association Publishing; 2023.