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Diagnosing Seung-Hui Cho

Mark Dombeck, Ph.D. was Director of Mental Help Net from 1999 to 2011. Dr. Dombeck received his Ph.D. in Clinical Psychology in 1995 ...Read More

"The ascent will eventually be betrayed to Gravity and descent will come, a falling like the bright Angel of Death itself." Pynchon – last page – "Gravity’s Rainbow"

Some of the many questions that people naturally ask about a traumatic event like the recent Virginia Tech shootings are something along the lines of, "What on earth is wrong with that guy?" or "What is it that motivates someone to kill so many people?" As each day progresses (today is Saturday), additional information on the background of Monday’s shooter Seung-Hui Cho is revealed in the media which helps paint a picture of who he was and what might have been troubling him. The amount of information will probably never seem sufficient to comprehend this tragedy. However, at this point, we do have enough information to venture some educated guesses about what psychological diagnoses might have applied to this kid, and what his state of mind might have been prior to the murders he committed.

As any practicing clinician will tell you, diagnosing mental illness diagnosis is a tricky business. There are no definitive tests for most mental illnesses. There is no quick and easy blood test or brain scan with results that allow us to say clearly, "Yes – this illness is present" or "No, this person doesn’t have a mental illness". Instead, making a mental health diagnosis is more like fitting facts to known patterns, always keeping in mind that there might be some alternative explanation that can better account for a particular person’s pattern of symptoms. In this essay, we’ll think out loud in order to provide you with a clearer, more understandable picture of the process of arriving at a diagnosis. Revealing the thought process behind making psychological diagnoses certainly won’t change anything, but we feel that it is a valuable exercise nevertheless.

The first thing to understand about mental illness diagnosis is that most clinicians rely on a standard guidebook or manual in order to help guide their thinking. Currently, the most widely used manual worldwide is the Diagnostic and Statistical Manual of Mental Illnesses, currently in its 4th edition, Text Revision (DSM-IV-TR). The DSM is published by the American Psychiatric Association. New volumes, reflecting advances in diagnostic and scientific knowledge, are published roughly once a decade. For years, the DSM has used a multi-axial system to assign diagnoses. In other words, diagnoses are made using a five axis system, and each person receives a diagnosis (if applicable) that has five separate components.

Axis I is used to record Clinical Disorders, e.g., disorders that were not always present for the person (e.g., they were healthy at one point, or at least they were initially free from a clinical disorder and then later developed one, typically as an adult, but not always). Problems like Major Depression, Panic Disorder and Schizophrenia fit on this axis.

In contrast, Axis II is used to record Personality Disorders and Mental Retardation. The common thread linking these two categories together is that they are both "developmental" disorders that have in some fashion always been around in the background affecting the person. Other developmental disorders like Autism are diagnosed on Axis I, however, so you need to keep in mind that the difference between Axis I and II is a relatively arbitrary and/or political distinction and classification more than a real one. For example, some Personality Disorders don’t appear until adolescence or early adulthood, so the notion that all Personality Disorders are developmental in nature is somewhat artificial.

Axis III is used to record any general medical conditions that might be affecting the person’s mental and behavioral state. For example, brain damage sustained from a traumatic head injury that caused memory loss and personality changes would be listed here. Similarly, if someone was depressed and had recently undergone open heart surgery, that surgery would be listed on Axis III as well. Axis III reflects current thinking about the interconnections between the body and mind.

Axis IV is used to record social, occupational, domestic and environmental stresses and concerns that are affecting the person. Recently immigrating to a new country, losing a job or a loved one, not having a home, experiencing marital troubles, etc. are the sorts of things that are are listed in Axis IV.

Finally, Axis V is used to record a single number, the Global Assessment of Functioning (GAF), that represents how well the person is coping. The GAF ranges between 1 (as bad as it gets) and 100 (as good as it gets). Someone who is having a peak moment in life might merit a 95, while someone who is about to hang himself after killing his wife might get a 5. The GAF scale is relatively concretely defined in the DSM with some common anchor points to guide clinicians in choosing an appropriate number.

Here is our preliminary (and necessarily inaccurate) DSM-style diagnosis for Seung-Hui Cho, based on the facts as we understand them from the media coverage. We acknowledge that our information is incomplete at best, and not necessarily sufficient for making a real diagnosis. The best way to make a diagnosis in "real life" involves collecting information from multiple sources, including a clinical interview with the person you are trying to diagnose. Obviously, that strategy is not possible. As a result, you need to treat what we write here with multiple grains of salt.

For Axis I, we are considering the following diagnoses:

Major Depressive Disorder with Psychotic Features

Schizophrenia, paranoid type

Schizoaffective Disorder

Delusional Disorder, persecutory type

Psychotic Disorder Due To (Medical condition? Drug reaction?)

We chose these Axis I disorders because we believe that there were two key aspects of Cho’s mental state prior to the murders: psychosis and a significant mood component. Psychotic, according to the DSM means "detached from normal shared social reality." What is the evidence for using the label "psychotic"? This is judgment call based on 1) the unprovoked nature of his attacks, which are highly atypical, and 2) our viewing of parts of the "multimedia manifesto" and listening to video of his voice and speech. His voice is monotone and his speech is "pressured", a term mental health professionals use to characterize rapid, often loud and emphatic, seemingly driven (as if they can’t get the words out fast enough), and usually hard to interrupt speech. His face is expressionless and emotionless, and the content of the manifest is irrational.

Psychotic states are characterized by delusions (fixed irrational beliefs) and/or hallucinations (hearing voices, etc.). There doesn’t appear to be any hallucination activity here, but the irrational manifesto suggests the presence of persecutory delusions (false beliefs that one is being punished, followed or harassed). Technically speaking, the manifesto is not "bizarre." The word "bizarre" is used in the DSM to describe delusions that are completely implausible, for example "Space aliens have replaced my brain with a remote transmitter and have made me into a robot". The content of Cho’s delusions is actually more plausible, having to do with being teased and persecuted by "rich people".
The fact that Cho’s delusions are non-bizarre, and that he did not seem to have hallucinations is a strike against the diagnosis of Schizophrenia, which is usually what people think of when they hear the term psychotic. A schizophrenic person can have non-bizarre delusions – that happens all the time – but often there are hallucinations present. Maybe Cho was experiencing hallucinations and he just wasn’t talking about them. If hallucinations were present, the diagnosis of Schizophrenia or Schizoaffective Disorder would be more appropriate. In the absence of hallucinations, something like Delusional Disorder (which is characterized by generally non-bizarre delusions without hallucinations present) seems more plausible.
Cho’s psychosis, according to terms in the DSM, was also not "disorganized". Some people with psychosis experience very disordered thinking and start to make seemingly random connections between topics they are discussing. They lose their ability to plan a day, make decisions, and/or to take care of themselves. This was not happening for Cho. His massacre was premeditated and well planned out, it seems. As we mentioned, his speech was pressured, but coherent at least at a syntax level. He appeared clean and groomed in his final photos. There was no "word salad" (schizophrenic speech that is confused and often repetitious, and strung together with no regard to the rules of language). Also – he was able to shift his attention from task to task while going about his rampage. He killed the first two students, went to the post office, and then returned to the campus to do some more killing. We can say that his capacity to make plans and shift his attention from task to task to carry them out (called "executive functioning") was intact. So, Cho was showing psychotic behavior, but it was occurring in a fairly organized and intact way.
Psychosis has to do with a disordered capacity for thinking and representing reality; but this term does not encompass mood symptoms. Cho was quite angry and rageful. His manifesto also makes clear that he felt hopeless and that his life was ruined. He was obviously suicidal as well as homicidal. So, we need to consider a diagnosis in addition to psychosis that can capture and describe these mood symptoms. A depressive episode would fit the bill. Whether Cho was truly experiencing a Major Depressive Disorder or a Bipolar Disorder (a disorder in which a person moves back and forth from a depressed to a manic state) is impossible to say. In the absence of any suggestion of previous manic episodes (elevated, expansive or notably irritable mood characterized by a decreased need for sleep, pressured speech, racing thoughts, impaired ability to pay attention, and risk taking behavior) in Cho’s life, we’ll go with the Major Depression diagnosis.
Depression can present in the normal form we’re familiar with (e.g., someone is blue, sad, melancholy), but it can also appear in an irritable, angry and agitated form, which would fit Cho. Depression is also characterized by social withdrawal, sleeping problems (Cho apparently had insomnia and rose very early in the morning), suicidal thoughts (he was suicidal in the past and both suicidal and homicidal at the end of his life) and recurring thoughts of death.
Depression itself can become so severe that it can cross into psychotic territory. This can be confusing for a clinician who is trying to determine whether someone is Depressed with psychotic features, or Schizophrenic. The correct diagnosis depends on the person’s pattern of psychosis and depression and how they influence one another. If the psychosis is a part of the depression, a historical pattern where Cho’s thinking became delusional primarily during periods when he was depressed would be noticeable. If the psychosis appeared when he wasn’t depressed, then proper diagnosis would be something more like Schizoaffective Disorder (a condition where psychotic and mood syndromes occur persistently but don’t appear to wax and wane in severity in any particularly synchronized fashion). We could also diagnose two conditions at once: 1) Schizophrenia and 2) Major Depression. In our experience, it comes down to regional, cultural differences as to who will diagnose the former and who the latter. When Dr. Dombeck was working at Yale Psychiatric Institute, they loved the Schizoaffective Disorder diagnosis. When Dr. Dombeck and Dr. Reiss worked in the San Francisco Bay Area, Schizoaffective diagnoses were less frequent. Exactly which labels a clinician would use to diagnose Cho is less important than making sure that both psychotic and mood components are reflected in the conditions.
On Axis II, Cho might meet the criteria for the following disorders:
Narcissistic Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Each of these potential personality disorders diagnoses are part of the "dramatic and erratic" Cluster B in the DSM classification system. Cluster B personality disorders all have to do with varying styles of social immaturity being present and expressed. In addition, these particular conditions need to be considered because they all share the extremely polarized "black and white" thinking and speech evident in Cho’s manifesto. Cho seemed to view the world in very stark terms shortly before his death. To him, his own pain was real and all-important; the pain of other people and his ability to empathize with them was decreased or totally absent. The writings, pictures and video footage suggested that he was experiencing a grandiose sense of victimhood and a martyrdom fantasy. In these communications, he characterized other people as evil, beyond redemption, and essentially only objects in his way. Viewing people as dehumanized objects that were persecuting him certainly made it easier to him to mow them down in the dorm and classrooms.
Narcissistic and Antisocial personality disorders share common themes. Both conditions are characterized by a rather extreme selfishness and a tendency to look upon other people as objects to be used and discarded. People with both conditions also tend to have a grandiose vision of self-importance. To the extent that Cho was objectifying others and seeing himself as the "King of Pain" for long periods of time and not just during a crisis, these diagnoses have to be considered. On the last day of his life, Cho’s intense self-focus and self-pity was clearly fueled by his black and white thinking.
The diagnosis of Antisocial PD seems especially relevant. People with Antisocial PD show a complete disregard for social rules and norms (including authority figures), display impulsive behavior and a reckless disregard for the safety of self or others, and are indifferent to the rights and feelings of others. It would be especially interesting to talk to Cho’s family in order to understand whether he showed a long-standing pattern of this type of behavior. Adults with this diagnosis often have childhood histories of being cruel to animals or people, setting fires, and repeatedly breaking rules or the law.
Borderline PD should also be considered because of the black and white thinking. In addition, Cho seems to have had difficulty with interpersonal relationships and self-image. Individuals with Borderline PD show extreme instability that often disrupts family and school life, as well as long-term planning. Again, it would be useful to talk to people who knew Cho for a long period of time in order to understand whether he demonstrated these patterns over a long period of time. As suggested by our discussion above, the Borderline diagnosis is not the only one with black ad white thinking as a symptom, but it is a hallmark of this disorder.
Though Cho’s actions betray his extreme black and white thinking and tendency to objectify others, these thoughts and resulting behavior may have been caused by the mood and psychotic disorders rather than a personality disorder. When people are angry and/or depressed, they tend to get very self-focused and self-absorbed and start to view the world and the self in very black and white terms (totally horrible, totally hopeless, etc.). It would have made it increasingly easy for Cho to have treated people like objects the angrier and more depressed he got. Having the opportunity to watch these symptoms wax and wane (if they did) would make it easier for us to say whether these were permanent features of his personality, or simply transient ones related to a current disorder.

Axis III
It doesn’t seem likely in this case, but it is possible for psychosis and mood disorders to be secondary conditions brought on by other medical conditions. A brain tumor, for instance, can cause psychotic symptoms. Surgery (particularly heart surgery) can also cause significant depression or psychotic symptoms after operations. We cannot assume that conditions are "psychological" just because they seem to be that way. Instead, we need to rule out the possibility that some underlying medical condition has occurred and thrown the brain off balance as a side effect. Since we have no information about Cho’s medical condition or history, we will leave his Axis III blank.
Axis IV is a big one for Cho. The stressors that likely affected him include:
  • Immigrant status
  • English as a second language
  • Racial/ethnic minority in Virginia
  • History of being bullied by other kids
That last stressor on the list is seems particularly relevant. It appears from news accounts that Cho was a teased and bullied child. Research suggests that childhood teasing and bullying are both major psychosocial stressors, and can set the stage for all sorts of problems in adulthood. Being brought from a foreign country to live in an entirely different culture, and speak an entirely different language as a young teenager is a major historical (and thus developmental) stressor as well. Adapting to a new culture and country would be much easier if you were an infant at the time you moved.
Certainly, Axis IV is not intended to provide "excuses" for Cho’s behavior. There are plenty of people who immigrated later in life and who were teased and/or bullied that didn’t go out and shoot people. However, Axis IV can help give us some context. Think about how much difficulty some kids experience moving from one school to another, and you may be able to think about how much difficulty Cho might have had moving to a new country.
Axis V for Cho is easy. Someone who methodically kills innocent people and then kills himself is obviously not displaying any sort of adaptive functioning. We’ll give him a GAF of "1" to reflect his functioning on the day of the murders. The GAF score would likely be higher on other days when things were not at such a crisis point.
There is some other information that we should mention that would help a clinician in formulating a diagnostic impression of Cho. Some of this information can help us make educated guesses about what was happening for him that led him to think that a violent rampage was a good idea. Again, please understand that explanation does not equal justification. As we mentioned previously, there are plenty of people that share one or more of these characteristics with Cho who don’t become mass murderers. However, as psychologists and trained observers of human behavior, we are taught to record and describe what is or was happening with a person that could create a situation where specific behavior is expressed.
In the manifesto photos, Cho goes out of his way to make himself look and act fierce. Why would he need to do this? "The lady doth protest too much, methinks". What we’re looking at is almost certainly what psychologist Alfred Alder termed "overcompensation." In this pictures, Cho portrayed himself as very menacing because internally he felt the exact opposite of fierce; he felt weak, vulnerable, a nothing. Because he went to so much trouble to compile his messages into a "media kit" and send them to a famous news outlet, it is obvious that he cared very much about people’s impressions of him.
Cho also felt ineffectual, beaten, defeated. He tried to get women interested in him, but they perceived him as a stalker. He tried to express himself through creative writing, but he ended up frightening everyone around him. He could not cope with this personal sense of complete failure, so he tried to transcend himself and become the image of a powerful, invulnerable super-man and overcome his inadequacies.
There have been suggestions in the media that "Ishmael Ax" (words that appeared on Cho’s arm and envelope) was code for a biblically inspired warrior based on Abraham destroying idols in the temple. Maybe in his paranoia, Cho actually thought he was this Ishmael; or maybe he merely wanted to think of himself as a warrior. It is unclear. Either way, however, he seems to have felt like a martyr or representative of persecuted or bullied people in general (another grandiose delusion) and felt responsible for exacting revenge. This revenge fantasy is another likely example of overcompensating for feelings of extreme vulnerability and inadequacy.
Why couldn’t Cho walk away from the anger peacefully? Why did he need to act out and harm other people rather than just retreating into a fantasy of power? Why did teasing affect him so greatly? We may never know. Teasing and bullying wounds most people, and many individuals on the receiving end of these negative experiences form fantasies of revenge. However, most fantasies are not aggressive or violent, and most people do not become violent in response to these fantasies.
It seems likely that Cho’s self-image was almost entirely based on feedback from other people (rather than incorporating some self-observations as well). He could not conceive of himself as a worthwhile individual without other people telling him so. He could not give acceptance to himself; instead, he needed it from other people. Because he could not compel people to like him or date him, through violence, he could compel them to take him seriously for a moment. His attempts to transcend himself and his situation failed in so many ways, but one way they failed in particular was that he could never stop himself from desperately seeking approval from others.
It also seems that Cho had problems coping with his emotions. Reports of his past behavior describe him as shy, quiet, and non-verbal. Perhaps he felt overwhelming social anxiety in addition to anger, and this was his over-controlled style of managing painful emotions. Rage that leads to a mass murder typically doesn’t accumulate all at once. Rather, it builds over time, like a pressure cooker. Cho didn’t seem able to use (apart from producing violent art work) any outlets for this mounting anger which was likely fanned by life experiences, black and white thinking, and underlying mental illness. Because he never learned appropriate strategies to express his anger, or because the strategies he used failed to work, he likely sought another method for expressing it. Because he lived in a country permeated by violent images and language, violence may have seemed like an appealing and easy way to get rid of the building internal pressure. It’s as though he build a dam around himself and shut off emotional expression rather than letting the pressure release. Dams have spillways so that when the pressure behind them gets too great, it can be relieved. Cho’s dam apparently did not have this safety feature; he let the pressure build up inside himself until he burst.
So, here is our preliminary and necessarily inaccurate diagnostic picture of Seung-Hui Cho, the Virginia Tech shooter. We can’t pin it down better than this and give you an easy or simplistic reason for Cho’s behavior. In addition, we will probably never have the amount of information we’d need to completely understand his thinking or behavior.
However, we hope that it is instructive to know the clinical thought process behind arriving at a psychological diagnosis, which we’ve hopefully illustrated. We also hope that our educated guesses are useful ways to organize your thinking about what happened. Arriving at an accurate diagnosis can be a difficult task. Human behavior is extraordinarily complex, people are "messy" and they don’t always fit neatly into circumscribed DSM categories. And most frustratingly, there are no scientific equations that allow us to plug in specific diagnoses and come up with a prediction equation to stop this from happening again. In other words, Major Depression with Psychotic Features+Antisocial Personality Disorder+recent immigration and bullying+anger+poor emotional coping skills does not necessarily = a mass murderer.
Keep Reading By Author Mark Dombeck, Ph.D.
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