The difference between a clinical sign, an outwardly observable indication of an underlying condition, and a symptom, a person’s subjective report of their discomfort, is crucial to understanding how the system can fail to “connect the dots” in time to prevent tragedy.
It happened once again, and only a few days ago: a man with a history of erratic behavior, some of which involved weapons, and who also had been showing several signs of mental problems, legally purchased a rifle, passed through a security checkpoint, entered a building where workers were present, and went on a shooting rampage that left 12 employees dead. Perhaps in no small measure because the incident occurred at the Navy Yard in Washington, D.C., many are asking how a person with the shooter’s history was able to obtain security clearance in the first place. Others are asking how anyone managed to pass a security check with a rifle in their vehicle. And in retrospect, now that certain other information has also come to light, many more are asking how all the signs indicating that Aaron Alexis was a man with serious mental problems making him potentially dangerous could have been so widely missed or disregarded. The answers to all these questions are likely to be slow in coming. But one aspect of this tragic circumstance deserves considerable attention: the process by which individuals who may have serious mental conditions are assessed.
According to CNN, the man officially identified as the Navy Yard shooter was a full-time army reservist from 2004 to 2011 when he was honorably discharged after a “pattern of misconduct”. He was also reported to have had episodic conflicts with military authorities, and, according to his father, to have problems with temperamental outbursts and “anger management,” which his family attributed to post-traumatic stress secondary to being actively involved in rescue efforts following the attacks on 9-11. He had a history of problems involving the use of guns and had at least two run-ins with the law, once in 2004 when he shot out the tires of a person’s car after he felt he’d been “mocked” (he reportedly stated he “blacked-out” during the episode and didn’t remember shooting), and again in 2010 when he fired a shot through the ceiling of his apartment in what he said was an accidental discharge while cleaning his weapon. His frightened neighbor and fellow apartment complex resident claimed it was a retaliatory act for her making too much noise. In the absence of convictions for any crimes in these incidents, however, he not only managed to secure an honorable discharge but also the necessary security clearance as an independent military contractor.
According to the Washington Post, in the days before the shooting, Alexis visited two different Veterans Administration hospitals, complaining of psychological concerns. Both visits occurred within days of Alexis calling police and complaining that he was hearing voices and that microwave vibrations had been coming through the walls of his room. During his second VA walk-in visit, staff report he complained of insomnia and according to those who evaluated him, denied thoughts of wanting to hurt himself or others. He was prescribed some medication (Trazodone, one of the earlier generation antidepressants commonly given to aid in sleep, reduce anxiety, and stabilize mood). And herein lies the two-fold problem facing so many mental health professionals these days when trying to accurately assess an individual’s mental health status, and especially to accurately assess the level of potential danger that might be associated with their mental illness: insufficient information upon which to make a fully accurate diagnosis, and over-reliance upon symptom reports as opposed to careful scrutiny of all the relevant clinical signs.
In these days of heightened protection of privacy and protection of rights, there are many obstacles in the way of securing sufficient collateral information to “connect the dots” with respect an individual’s potentially dangerous clinical state, especially when that individual is not displaying florid, obvious signs of acute and severe mental illness at the moment and is not being brought to the attention of clinicians by an objective third party who has ample, credible, relevant, information about the person’s behavioral history. Although the terms are often poorly understood, a clinical sign is an outwardly observable indication of an underlying condition, as opposed to a symptom, which is a person’s subjective report of their discomfort. Some signs are fairly dramatic, unmistakable, and sometimes so indicative of an underlying condition that they’re nearly diagnostic in themselves. For example, a person might speak in such a rapid and energetic fashion that they can barely catch their breath (this sign is often referred to as “pressured speech”). It can be a sign that someone has experienced acute stress or is under the throes of a mood disorder. Sometimes a person speaking this way might also jump from topic to topic but express ideas that are largely fragmented and unrelated (sometimes referred to as “flight of ideas”). And when these two signs appear together, it’s a fairly reliable indication the person is in a manic state. (Other possibilities do exist, however, and there can be other reasons other than a mood disorder for the manic state — e.g., recent mood-elevating drug ingestion — so, good clinicians consider all the evidence in surveying the various other options.) Symptoms are different, however. They’re what the person reports, based on their subjective experience. And an evaluating professional relying on a symptom report is always at the mercy of the patient’s accuracy, truthfulness, and completeness in reporting. Besides, sometimes what the patient reports is diametrically opposed to what is being observed. For example, a patient might claim they “can’t breathe” when all objective evidence indicates they are breathing normally (as might be the case during an episode of anxiety-related “air-hunger”). That’s why accurate diagnosis can never depend primarily on symptom reports.
Research tells us that we’re simply not very good at predicting dangerousness. But every event like the Navy Yard shooting incident makes it clear how important it is for us to get better at this task, especially when it comes to professionals assessing the seriously mentally ill. Because we live in an unprecedented age of information availability, it would seem like we should be doing a better job at this. But making sure the right people have access to all the right information they need and in a timely enough manner to help prevent the kind of nightmares we see all too often is a much more complicated and challenging task than it appears at first glance. When these tragedies occur, it seems so easy to “connect the dots” after a retrospective examination of all the facts. But given the way the rules are set up now, and the manner in which clinics typically staff and conduct their diagnostic procedures, it’s almost impossible to get all the necessary information to all the right persons and places in advance to head off disaster. It will likely take years and the very mindful attention of lawmakers and medical supervisors to improve this situation. We already know many of the “signs” that point to danger. But we need to get a lot better at screening for them and taking the appropriate actions when we spot them.
All clinical material on this site is peer reviewed by one or more clinical psychologists or other qualified mental health professionals. This specific article was originally published by Dr Greg Mulhauser, Managing Editor on .on and was last reviewed or updated by