Any time there's a violent tragedy - such as the killing of at least 86 people at a youth camp in Norway - one question seems to ring clearer than others: Why didn't someone notice beforehand that the suspect might be disturbed and capable of committing deadly violence?
Psychiatrists and mental health experts say there are some clear warning signs that a person could be suffering a mental breakdown and needs help.
"The road to the crisis is often long, and there are a lot of signposts," said Bryan Gibb, director of public education for the National Council for Community Behavioral Healthcare. "It's our job to educate people about those warning signs so people can get the treatment they need early."
But the experts also warn that a breakdown rarely leads to violence. "It's the rare person who has an extreme form of behaviour that becomes either violent or self-injurious," said Dr Thomas Wise, a professor in the psychiatry and behavioural sciences department of Johns Hopkins Medicine in Baltimore and chairman of behavioural health services for Inova Health Systems in Fairfax, Va.
How to spot a psychopath
People prone to mass violence often have fallen victim to an "overvalued idea", a psychiatric term for an unreasonable belief over which the person has become obsessed, Wise said.
Overvalued ideas are not delusions, in that people with overvalued ideas are not completely and irrationally fixed in their beliefs despite any evidence provided them, he explained. The irony is that people suffering from delusions and clearly mentally ill, he said, are less likely to commit violence than people teetering on the brink of obsession who are not technically suffering from a mental disorder.
"People who have overvalued ideas often act on them," Wise said. "People with delusions do not. They often are surprisingly passive, given all the conspiracies they believe surround them."
Public interest in better identifying people in crisis has increased in recent months, said Gibb, whose group helps sponsor Mental Health First Aid classes across the country aimed at preparing people to spot signs of trouble and intercede.
"Calls to us increased quite dramatically after Tucson," Gibb said.
Any talk of violence, either to oneself or to others, should be considered a clear warning sign, both men said.
"When you talk about things that are uncomfortable and potentially violent, in our culture that is highly unusual, threatening and should give someone pause," Wise said.
It's even more worrisome if the person has no idea that the way he or she is talking or acting is disturbing those around them. "If he has no sense of how he affects others, that's a sign of trouble," Wise said.
Warning signs to look out for
People should especially be on alert if a person who has been agitated and talking of violence for some time suddenly becomes calm and placid. That could mean that the person's internal conflicts are over, and he or she is intent on action.
"When they set up a plan, they no longer feel conflicted," Gibb said. "They can almost feel euphoric because they've made that decision."
A past history of violence is another predictor of whether someone with a mental problem might act out. Drug and alcohol use also can be a warning sign, particularly with someone who has already been acting strangely, Gibb and Wise said.
People exhibiting these warning signs should be confronted, but gingerly, they say.
Wise recommends having a heart-to-heart talk with the person in a public place. "Let them know, 'Hey, you're scaring me a little bit,'" he said.
Reaching out to the person's friends and family is important, too, he said. The more people who know about the problem, the more likely the person will be willing to accept help from someone.
Gibb agreed, adding that it's important to try to de-escalate the person's mood. Listen to them, calm them down and offer help -- even if the help is as simple as fetching a glass of water.
"It sounds hokey, but we teach about the 'ministry of presence,'" Gibb said. "Tell them you're here and you want to help. 'Hey, I noticed you seem kind of upset. Is there something I can do for you?'"
The American Psychiatric Association has more about the warning signs of mental illness.
SOURCES: Bryan Gibb, director, public education, National Council for Community Behavioral Healthcare, Washington, D.C.; Thomas Wise, M.D., professor, department of psychiatry and behavioral sciences, Johns Hopkins Medicine, Baltimore, and chairman, behavioral health services, Inova Fairfax Hospital, Fairfax, Va.
Last Updated: July 29, 2011
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