Having watched the videos from Cho on NBC news, there’s something that’s not being said. This is Chronic Paranoid Schizophrenia. This endless diatribe against un-named persecutors, his attempt to use escalating metaphors to describe his own torment, his talking about being forced to do this, his description of himself as a martyr, are all the dialogue of a psychotic process that has been present for a long period of time. Note also, in spite of occasional grimaces that it’s delivered in a monotonous almost emotionless rant. I came into Psychiatry after the advent of the antipsychotic drugs so I wasn’t around during the era when chronic cases such as this were very common, but I saw enough such people to know what I was seeing on those tapes.
There are some parameters that have been reliably used to predict the outcome. One is the pre-morbid adjustment. The better adjusted the person prior to the onset of the ouvert symptoms, the more likely it is for there to be a favorable outcome. From what we hear, Cho has always been a withdrawn loner, a social isolate. Another predicter of outcome is the kind of onset. People who have a rapid and flagrant initial outbreak of the illness tend to do better than people who seem to just drift into their illness. There are any number of symptomatic forms of Schizophrenia. The type with the worst prognosis [outcome] is Paranoid Schizophrenia. So Cho’s lifelong withdrawal, the insidious deterioration suggested by his history, and the predominance of his Paranoid symptoms are all negative signs.
In an era before any treatment was available, Cho would have likely been sent to the State Hospital where he would have lived out his life. In a modern era, he’s the kind of case that’s hardest for mental health systems to deal with. He would be unlikely to seek or comply with treatment. Paranoid symptoms are the least responsive to medications. He would frighten people, but would be unlikely to be kept by a modern hospital. He would not be eminently dangerous nor particularly treatable. He was so withdrawn and remote that the only way his internal torment would be apparent would be in his writing.
In spite of their tortured experience and constant paranoid preoccupations, such people often describe feeling dead inside, and have a pervasive flatness within called anhedonia – the absence of pleasurable emotions. Schizophrenia is an illness. There’s no evidence that it is the result of psychological forces, or volition. It can occur in almost any circumstances, in every culture. It’s "cause is unknown" in spite of herculean efforts to find a biological basis for the illness. And with cases such as Cho, cases that are so devastating, the advances in treatment in the latter half of the last century are miraculous compared to the centuries before.
Schizophrenic people are no more likely to kill than the general pupulation. That said, when they do, they often do so in a bizarre fashion like Cho, or Son of Sam, or the Unibomber. This man was too sick to leave unchecked in a college milieu. I don’t have any idea what would have happened if he’d been expelled, but he obviously couldn’t manage being there. For all anyone knows, he could have come back from home and done the same thing. But there was no reason in the world to allow him to stay in a situation that he obviously couldn’t manage. It sounds to me like he slipped through the cracks because he was mostly quiet, and no one could figure out what to do either with him or for him. The outcome is an unspeakable tragedy.
What now? College Campuses will live in a heightened state of awareness for all time for such cases, and will act definitively. Cho will become a symbol of how wrong it is to overlook one. As for why what was wrong with Cho remains mostly un-named in the Press? I haven’t a clue…