On April 16, 2007 23-year-old Seung-Hui Cho, a student at Virginia Tech University in Blacksburg, Virginia, USA, shot to death 32 students and faculty members, wounded many more, and then committed suicide. From an early age Cho was seen to have few thoughts and mutism, a spokesman for Virginia Tech describing him as “a loner.” Several of his professors noted that his writing had violent themes, and encouraged him to seek counseling. A psychiatrist evaluated Cho after he expressed suicidal thoughts to a roommate, a probate judge finding him to be mentally ill and ordering him to seek outpatient treatment.

More is known about the massacre than at first meets the eye. While the media has taken to using the word “rampage” the correct word, historically, culturally and medically, is “amok. In this article I will reinforce the hypothesis that amok is a manifestation of mania. While other psychiatric disorders can disable or destroy their victims, manic-depressive disorder sometimes bestows extraordinary gifts on those in its grasp. Mania gives the fortunate ones unlimited ambition, and enough confidence in their powers to try to achieve their dreams, putting the brain into high gear, increasing the speed of thinking, speech and everything he does. It floods him with ideas and energy. While the benign variant has given us geniuses, its paranoid, megalomaniacal twin has unleashed bigots, mass murderers and warmongers. The disorder has produced the great destroyers of history, when in addition to ambition and egotism have been added ruthlessness, willfulness, intolerance of criticism, a consuming need to dominate others, paranoia, an indifference to the suffering of others, and such delusions as those of omniscience, invincibility and infallibility.(1) The paranoid and grandiose delusions of a despot are as infectious as a contagious virus, and can easily infect those in thrall to the host figure, a phenomenon known as induced psychosis and regularly seen on the world stage.

In the sixteenth century Portuguese travelers observed Javanese who would go out in the street and kill as many persons as they met, before others subdued or killed them, or they committed suicide. Malaysians called these people Amuco, amok literally meaning murderous frenzy or rage. Amok was traditionally attributed to loss of face, shame, humiliation, jealousy, or provocation. (2-7) That amok is an expression of manic-depressive disorder is suggested by the preliminary symptoms: before the attack, the killer is typically preoccupied, withdrawn, brooding and apathetic - in other words, depressed. Following the attack the perpetrator is often fatigued, amnesic and suicidal. In his epic “Manic Depressive Insanity and Paranoia” (1921) Emil Kraepelin, the renowned expert on manic-depressive disorder, was the first to suggest that amok is an expression of enraged mania. (8) Others refer to the attack as the outcome of switching from depression into manic agitation.(9) Amok, it would seem, may well be a manic equivalent, and not confined to mass killing. What marks amok may not be the numbers alone but the savagery, when the victims are raped, mutilated, cannibalized or beheaded.

In “A Brotherhood of Tyrants: Manic Depression and Absolute Power,”1994 Amherst Prometheus Books,(1) D Jablow Hershman and I coined the term “battle mania” to describe the rapidity of thought, action, aggressiveness, alertness, daring, and superhuman energy that danger may induce in anticipation of or during battle. “Amok” and “battle mania” would seem to be interchangeable. Napoleon was manic when he defeated a vastly superior force at Austerlitz, going for five days and nights without sleep and riding five horses to death. At Borodino, he began the day with manic optimism, but when the tide of battle began to go against him slumped into a state of lethargy, disinterest and indecision in which he was unable to give orders.(1) Hitler’s mania carried him to the threshold of triumph at Dunkirk, but the depressive apprehension that the French had set a trap deprived him of it when he ordered his generals not to advance.(10) Hershman and I note that what puts its stamp on mass killing is the enraged manic’s indifference to the suffering of others.(1)

Kraepelin and Sigmund Freud were both born in 1856, and became lifelong rivals. In America, Freud became a household name, Kraepelin known to a very few. The full spectrum of manifestations of manic-depressives is not widely appreciated. The media commonly attributes environmental factors, and not mental illness, to various forms of violence. A study at the Karolinska Institute has shown, however, that 90% or more of murderers are mentally ill, many of them depressives or manic-depressives.(11) Epidemiologists claim that about 1% of the population will develop manic-depressive disorder. This figure is an underestimate, as it reflects only the most severe cases. Manic-depressive disorder is not a conspicuous illness, except in its most extreme stages. It may masquerade as compulsive gambling, alcoholism, drug addiction, promiscuity, sexual indiscretion, serial killing, bankruptcy, scholastic failure, and attention defect hyperactivity disorder. Innumerable manic-depressives have been misdiagnosed as schizophrenics, borderline personalities and narcissistic personalities. At Harvard, Pope and Lipinski showed that there is neither symptom nor constellation of symptoms that distinguish schizophrenia from manic-depressive disorder.(12) The symptoms of manic-depressive disorder are qualitatively identical to those of normals, but reach a much higher level of intensity, sometimes to extremes. In the case of Cho, one wonders whether the diagnosis made was one of depression or manic-depressive disorder. Cho had a multitude of symptoms of severe depression, his mania expressed in amok. Kraepelin pointed out that mania and depression are not always separate entities, and both may operate concomitantly.

Many drug companies have become enamored of manic-depressive disorder, and one encounters manic-depressives taking anticonvulsants or atypical antipsychotics whom in an earlier age would be taking lithium. The price differential is the key as is the policy of many drug companies to “grow the market.” As far as finger pointing is concerned, one cannot overlook managed care denying hospitalization for many who need it for their own protection or that of others. The manic-depressives of Kraepelin’s time might spend months, or even years, in a hospital; today they may be fortunate to spend a few days. The Cho amok was due to many factors, not the least systemic problems with probate. We need to ask why he was not kept under probate in a hospital, and society needs to take a hard look at the boundaries between medicine and law. We have a sad tradition in the United States of allowing judges to sentence the non-violent and alas violent to “counseling.” “Amok” and not “rampage” is a diagnostic term in DSM IV, and the media should refrain from inventing its own psychiatric terminology.(13) It is often impossible to reason with despotic leaders, dooming diplomacy to fail. One should not think that stopping homicidal manics is easy, considering what it took to stop Bonaparte, Wilhelm II, Hitler, Stalin, and Hussein.(14)

Posted by Julian Lieb, M.D.

References:

1. Hershman D Jablow, and Lieb, J. “A Brotherhood of Tyrants: Manic Depression and Absolute Power.” 1994. Amherst. Prometheus Books.
2. Westermeyer J. A comparison of amok and other homicide in Laos. Am J Psychiatry. 1972 Dec; 129(6): 703-9.
3. Kon Y. Amok. Br J Psychiatry 1994 Nov; 165(5): 685-9.
4. Hatta S M. A Malay cross-cultural worldview and forensic review of amok. Aust NZ J Psychiatry 1996 Aug; 30(4): 505-10.
5. Hempel A G, Levine R.E, Meloy J.R, Westermeyer J. A cross-cultural review of sudden mass assault by a single individual in the oriental and occidental cultures. J Forensic Sci. 2000 May; 45(3): 582-8.
6. Saint Martin M L. Running Amok: A Modern Perspective on a Culture-Bound Syndrome. Prim Care Companion J Clin Psychiatry 1999 Jun; 1(3): 66-70.
7. Adler L, Marx D, Apel H, Wolfersdorf M, Hajak G. Stability of the “amok runner syndrome.” Fortschr Neurol Psychiatr 2006 Oct; 74(10): 582-90.
8. Kraepelin E. Manic-Depressive Insanity and Paranoia.1976; New York, Arno Pr: 194.
9. Schmidt K, Hill L, Guthrie G. Running amok. Int J Soc Psychiatry 1977; 23(4): 264-74.
10. Payne, R. “The Life and Death of Adolf Hitler.” 1973 New York, Dorset
11. Fazel S, Grann M. Psychiatric morbidity among homicidal offenders: a Swedish population study. Am J Psychiatry 2004 Nov; 161(11): 2129-31.
12. Pope H G and Lipinski. Diagnosis in Schizophrenia and Manic-Depressive Illness. Arch Gen Psychiatry 1978 Jul; 35: 811.
13. Gaw A C, Bernstein RL. Classification of amok. In DSM-IV. Hosp Community Psychiatry 1992 Aug; 43(8): 789-93
14. Lieb, J.”Two manic-depressives, two tyrants, two world wars.” Medical Hypotheses (2008) 70, 888-892