I believe James Holmes, the shooter in the Batman/Aurora Colorado theater tragedy will be found to be suffering from a severe mental illness with a violent homicidal psychosis. Specifically, I think he will be diagnosed as having Paranoid Schizophrenia with an underlying Schizotypal (S) or Antisocial personality disorder (APD). While rare, this combination of conditions (see Jared Lee Loughner, the man accused of the Tucson shooting spree crime and the cluster of symptoms displayed by Robert DeNiro’s quirky character Travis Bickle in the movie Taxi Driver) can result in an identifiable spiral into “violent psychosis” or controlled (as opposed to impulsive) homicidal behavior when ideas of reference transition over time and under stress into “delusions of reference” (see below) as it did for John Hinkley in his delusional obsession with the actress Jodie Foster in the movie Taxi Driver, by coincidence. In fact Hinckley watched the movie 15 times in a row…….creepy much?

Taxi Driver clip:   http://www.youtube.com/watch?v=lQkpes3dgzg

I suspect that it will be revealed that James Holmes, while quite bright intellectually , was struggling to keep up academically in his Ph.D. program in Neuroscience at the University of Colorado. As a result of growing cognitive problems, ongoing sleep difficulties, and increasing symptoms of severe mental illness (psychosis including ideas of reference) he was either asked or pressured (or voluntarily elected) to withdraw from his academic program which then became a trigger to his worsening psychiatric condition and disturbed behavior. Lacking self esteem and security in his self perceived academic/intellectual identity (against a consistent background of prior high achievement) he was also about to be forced out/evicted from his graduate student-only housing. I believe these multiple stressors and perceived rejections precipitated his rapid descent into madness/violence. On a reality level there was “no going back” in his life (and current predicament) which ironically was a philosophical and scientific subject of interest he explored earlier in his life at science camp in San Diego (see video) where he studied “Temporal Illusions” or as he said it, “I’ve been working with a temporal illusion. It’s an illusion that allows you to change the past.”

I believe like the movie character Travis Bickle, James Holmes instead began to construct an “alternate reality” and pseudo identity for himself as “The Joker” to cope with his growing psychiatric problems, feelings of alienation and pre-existing social anxiety. Based on his relatively isolated loner type personality, he needed to see himself both as a coherent and powerful character (such as the Joker in Batman, see description below) as well as someone who could “successfully” act out his violent delusional fantasies. In his case (again quite rare) the boundary line between video game killing, movie violence, and gaming/computer generated alter-egos/actual violence became progressively blurred. Such a personality is then capable of focusing themselves into highly organized and well orchestrated plans to commit mass violence. Such a plan included the construction of home-made bombs in his residence purchased from materials bought off the internet for a period of many months. Whether or not James Holmes had a history of being bullied in school or harassed for being different or “weird” earlier in life will turn out to be less relevant than his progressive loss of reality testing and developing psychotic obsessions/violent fantasies/delusions. Whether such a diagnosis will ultimately reflect on or impacted his ability to tell “right from wrong”, a necessary feature of an “insanity” defense, is not debated here. It will, without a doubt, be debated in court.  Such a defense, while difficult at best can be used properly but unsuccessfully as well as improperly but successfully (see John Hinckley and/or the Unibomber case and Ted Kaczynski).  This behavioral profile and diagnosis is made based on early and rather spotty news reports, videos, and biographical information as well as logical deduction utilizing basic forensic principles and crime analysis.

Additional Notes:  Notice the irony of the violent ad shown before the video of James Holmes at science camp:    http://www.heavy.com/news/2012/07/18-year-old-james-holmes-talks-temporal-illusions-in-video/

The Joker:  Throughout his comic book appearances, the Joker is portrayed as a master criminal whose characterization has varied. The original and currently dominant image is of a highly intelligent psychopath with a warped, sadistic sense of humor, while other writers have portrayed him as an eccentric prankster. He has been repeatedly analyzed by critics as the perfect adversary for Batman; their long, dynamic relationship often parallels the concept of yin and yang. As one of the most iconic and recognized villains in popular media, The Joker was ranked #1 on Wizard’s list of the 100 Greatest Villains of All Time.[3]   James Holmes was the kind of person who wanted to be “the best”, so he picked the very “best” villain to be. His focus on high achievement thus carried over to his psychotic delusions.

Ideas of reference and delusions of reference:

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This article is about a mental illness.
Ideas of reference and delusions of reference involve people having a belief or perception that irrelevant, unrelated phenomena in the world refer to them directly or have special personal significance: ‘the notion that everything one perceives in the world relates to one’s own personal destiny’.[1]

In psychiatry, delusions of reference form part of the diagnostic criteria for psychotic illnesses such as schizophrenia,[2] delusional disorder, or bipolar disorder during the elevated stages of mania. To a lesser extent, it can be a hallmark of paranoid personality disorder. Such symptoms can also be caused by intoxication, especially with hallucinogens or stimulants like methamphetamine.

[edit] Delusions of reference:

‘Ideas of reference must be distinguished from delusions of reference which may be similar in content but are held with greater conviction’.[11] With the former, but not the latter, the person holding them may have ‘the feeling that strangers are talking about him/her, but if challenged, acknowledges that the people may be talking about something else’.[12]

At the same time, there may be ‘transitions…to delusions’ from ideas of reference: whereas ‘abortive ideas of reference, in the beginning of their development or, in Schizotypal personalities, continuously, may remain subject to the patient’s criticism…under adverse circumstances, by minimal economic shifts, however, reality testing may be lost and daydreams of this kind turn into delusions’.[13]

It has been noted that the character ‘rigidly controlled by his superego…readily forms sensitive ideas of reference. A key experience may occur in his life circumstances and quite suddenly these ideas become structured as delusions of reference’.[14] Within the ‘focus of paranoia…that man crossing his legs, that woman wearing that blouse – it can’t just be accidental. It has a particular meaning, is intended to convey something’.[15]

Persons with ideas of reference may experience:

Believing that ‘somehow everyone on a passing city bus is talking about them, yet they may be able to acknowledge this is unlikely’.[16]
A feeling that people on television or radio are talking about or talking directly to them
Believing that headlines or stories in newspapers are written especially for them
Believing that events (even world events) have been deliberately contrived for them, or have special personal significance for them
Believing that the lyrics of a song are specifically about them
Seeing objects or events as being set up deliberately to convey a special or particular meaning to themselves
Thinking ‘that the slightest careless movement on the part of another person had great personal meaning…increased significance’.[17]

Robert DeNiro/Travis Bickle emerging symptoms of Violent Schizophrenia and Schizotypal  Personality Disorder in the movie Taxi Driver: A Psychiatric Cinematic Analysis (see below) 

Movie Scene
Taxi Driver :Content Description and Various Symptoms

Introduction

Schizophrenia spectrum; Negative and cognitive symptoms; Prevalence; Odd cluster; Introduction of  Schizctypal Personality Disorder to DSM

Scene 1: Start

Scene 2: Travis Bickle

Vocational issues; Peculiar ideas; Schizotypal Personality Disorder and the military; Useful psychological testing; Vague descriptions; Childhood symptoms; Biosocial formulation; Functional impairment; Psychiatric rehabilitation; Tangential digression; DSM-IV-TR diagnostic criterion A(4) for Schizctypal Personality Disorder: Verbal deficits and speech; The challenge of interpersonal relationships
Scene 3: Tom & Betsy

Stalking; Dangerousness; Frontal confrontation
Scene 4: Wizard’s Court

DSM-IV-TR diagnostic criterion A(6) for Schizctypal Personality Disorder: Affective style; DSM-IV-TR diagnostic criterion A(5) for Schizctypal Personality Disorder: Suspiciousness and paranoid ideation; Cognitive-behavioral formulation; DSM-IV-TR diagnostic criterion A(1) for Schizctypal Personality Disorder: Ideas of reference

Scene 5: A New Volunteer    Unusual language; Idiosyncratic phrasing and construction; Impaired reality testing; DSM-IV-TR diagnostic criterion A(2) forSchizctypal Personality Disorder: Telepathic, paranormal and superstitious communication; Bizarre fantasies; DSM-IV-TR diagnostic criterion A(7) for Schizctypal Personality Disorder: Odd behavior and appearance; Ruminative cognitive style; Another look at speech patterns
Scene 6: Charles Palantine

Bizarre thinking, behavior and speech; Empathetic and understanding interviewing
Scene 7: Aborted Fare

Ideas of reference
Scene 8: A Date with Betsy

DSM-IV-TR diagnostic criterion A for Schizctypal Personality Disorder; Social and interpersonal deficits; inattentiveness to social conventions; DSM-IV-TR diagnostic criterion A(3) for Schizctypal Personality Disorder: Impaired reality testing; Transient psychotic episodes
Scene 9: Confrontation

Unkempt appearance; A trigger: Close interpersonal relationships; Obsession…enmity; Therapeutic relationships; Internal/external rage; On being an object of an obsession; Unusual words or concepts; Psychodynamic formulation of Schizctypal Personality Disorder

Scene 10:Curbside Cuckold

Dangerous absence of insight; Ideas or reference
Scene 11: A Word with Wizard    DSM-IV-TR diagnostic criterion A(8) for Schizctypal Personality Disorder: Lack of close personal relationships; Inability to reach out to mental health professionals
Scene 12: Running into Iris

A psychologically variant theme; Diminished desire for intimate contact; Biosocial formulation; Impaired reality testing
Scene 13: Easy Andy

Psychdynamics of a stalker

Scene 14: Henry Krinkle

Sinking lower into derangement; Odd appearance; Social skills deficits; Cumulative effect of ideas of reference

Scene 15: You Talking To Me?

Out of his mind
Scene 16: Market Robbery

Metaphors become different characters; Permission for violence

Scene 17: Late for the Sky

Last bit of reality

Scene 18: Dear Father and Mother

Those most vulnerable to stalking; Idiosyncratic phrasing; and construction; Impaied reality testing; Familially of Schizctypal Personality Disorder – psychodynamic, biosocial, interpersonal

Scene 19: TV Critic

Intensity of the stalker’s emotions

Scene 20: Looking for Action

Affective style of a person with Schizctypal Personality Disorder;  Inattentiveness to social conventions

Scene 21: A $10 Room

Diminished desire for intimate contacts; Inability to deal with sexuality
Scene 22: Breakfast with Iris

Impaired reality testing; Ideas of reference; Fearful and dismissing attachment style; Verbal episodic memory deficits
Scene 23: Dancing with Sport

Imagining his rival with Iris; Danger when reality conflicts with distortions

Scene 24: The Palantine Rally

Odd, eccentric and peculiar appearance; Pharmacology for Schizctypal Personality Disorder

Scene 25: Suck on This

Schizctypal Personality Disorder: Stability vs. psychosis

Scene 26: Shooting Gallery

Psychotic violence

Scene 27: Bang, Bang, Bang

Schizotypal Personality Disorder: Most are not dangerous

Scene 28: Dear Mr. Bickle

Madman vs. sane man; Normalcy does not last; Insight-oriented psychotherapy; Supportive psychotherapy; Cognitive-behavioral therapy; Family and group therapies; Introducing medication

Diagnostic Note

Travis demonstrates DSM-IV-TR diagnostic criteria for Schizctypal Personality Disorder

References

Excerpt from Scene 2: Travis Bickle
The main character, Travis Bickle, is introduced as he walks into the office of a New York City taxi cab company and inquires about a job as a driver.
It is not surprising that Travis is applying for this type of job because people with Schizctypal Personality Disorder gravitate toward jobs that demand little interaction with others (Sperry, 2003, p. 242).

He tells the interviewer that he wants to drive a cab because he cannot sleep nights and that going to all night porno movies has not been a helpful alternative. When the interviewer asks Travis what he does now, while most people would offer a response about their employment or vocational activities, Travis follows the conversation thread he had begun and responds:

Now? Ride around nights mostly. Subways, buses. [I] figure, you know, [if] I’m gonna do that, I might as well get paid for it.

Interviewing people with Schizctypal Personality Disorder usually elicits surprising statements and peculiar ideas (Sperry, 2003, p. 249).

Travis is a 26 year old US Marine veteran of the Vietnam War. He seems to identify with that role as he wears a Marine jacket with a patch from his King Kong Company and displays a Vietnamese flag in his impoverished, messy apartment. Travis’ success at becoming a Marine leads to speculation that Travis was able to meet high standards. However, other than the fact that he was a Marine no real information about Travis’ military career is revealed to support such speculation.

In addition to observation, the Minnesota Multiphase Personality Inventory (MMPI-2), the Million Clinical Multiaxial Inventory (MCMI-III), and the Rorschach Psychodiagnostic Test can be useful in diagnosing Schizctypal Personality Disorder. On the MMPI-2 a 2-7-8 (depression-psychasthenia-schizophrenia) code is likely. Scales F (frequency) and O (social introversion) are also likely to be elevated. On the MCMI-III, elevations on S (schizotypal), 2 (avoidant), 7 (obsessive-compulsive), and 8A (passive-aggressive) can be expected. On the Rorschach, these individuals have records that are more similar to schizophrenics and borderline personality-disorded individuals than to schizoid individuals (Sperry, 2003, p. 250). The Multidimentional Personality Questionnaire (MPQ) has been found to be a powerful measure of personality that has been used in research. It is a paper-and-pencil true/false test that has used to identify personality correlates of violence and crime across cultures, countries race and gender (Nestor, 2002, p. 1977).

In contrast to the impressive record inferred by having been a Marine, Travis offered a very unimpressive response to the question about his education:

Travis: Some, Here, there, you know.

People with Schizctypal Personality Disorder are prone to vague descriptions. Perhaps, also related to this response is the fact that the symptoms of Schizctypal Personality Disorder may begin in childhood or adolescence showing as a tendency toward solitary pursuit of activities, poor peer relationships, pronounced social anxiety, and underachievement in school. Other symptoms that may be present during the developmental years are hypersensitivity to criticism or correction, unusual use of language, odd thoughts, or bizarre fantasies. Children with these tendencies appear socially out-of-step with peers and often become the object of malicious teasing by their peers, which increases the feelings of isolation and social ineptness they feel (Gilles, 2003).

Travis leads a dark, lonely and isolated life where he seems to be confined to his depressing apartment, the dreary taxi cab he drives or a shady movie house showing pornographic films.
This is consistent with the biosocial formulation reported by Sperry (2003, p. 246) which is that Schizctypal Personality Disorder is self-perpetuated by social isolation, overprotection and self-insulation. While social isolation has immediate benefits, in the long run they are counterproductive as they deprive these individuals of opportunities to develop social skills and they foster dependency. Furthermore, the individual’s tendency toward self-insulation further perpetuates the spiral of cognitive and social deterioration that typifies Schizctypal Personality Disorder.

Travis fills his body with junk food, drugs and alcohol, the latter two which he carries with him when he is out of his apartment. He lacks the interpersonal skills to make acceptable conversation as exemplified in the work environment with the boss and in the social environment of the movie house where he tries to make social conversation with the woman working at the snack counter. In both examples he forces the other person to threaten him in some way in order to get him to stop.
This exemplifies the initial results from the Collaborative Longitudinal Personality Disorders Study, one of the first studies to document and quantify the extent of functional impairment in patients with an Axis II disorder in contrast to patients having an impairing Axis I disorder. Patients with Schizctypal Personality Disorder were found to have significantly more impairment at work, in social relations, and in leisure activities than patients with Axis I obsessive-compulsive or major depressive disorder…These results not only underscore the misconceptions that clinicians have been known to have of the extent of psychiatric morbidity attendant to Axis II disorders but also suggest the importance of utilizing integrative treatment interventions that emphasize psychosocial rehabilitation to mitigate the pernicious effects of personality disorders on functioning (Sperry, 2003, pp. 18-19).

Another important note here is that the comment that agitated the boss, the comment about Travis’ conscience being clear, was a tangential digression, another symptom to which people with  are prone (Gilles, 2003).

Travis’ only uneventful verbal communication occurs in his living environment where he is alone and writes in his diary.

When Travis is asked if the taxi driver job would be “moonlighting” for him, Travis does not know what the term “moonlighting” means.

This may be due to verbal episodic memory deficits, a well-established feature of the schizophrenia spectrum that has been found in individuals with Schizctypal Personality Disorder. In an NIMH Grant supported study comparing individuals with Schizctypal Personality Disorder to individuals with other personality disorders and a group of healthy volunteers those with Schizctypal Personality Disorder learned verbal and visual-spatial information at a reduced rate and recalled fewer words and objects after a long delay (McClure, et. al., 2006). Another explanation may be that people with Schizctypal Personality Disorder may have speech patterns that appear strange in their structure and phrasing…and some may verbalize their responses by being overly concrete. Thus, Travis may use such a term to mean “lighting the moon” (Gilles, 2003).
Travis, however, does get the job. One may speculate that it was not because of his interview behavior but, rather, because the interviewer appears to feel some comradery with a fellow marine and because Travis is willing to do what the interviewer needs, i.e., someone who is willing to drive on Jewish holidays and to drive nights and work uptown, South Bronx and Harlem.
Travis sees the world as dirty and “venal”:

Thank God for the rain, which has washed away the garbage and the trash off the sidewalks…All the animals come out at night. Whores, skunk-pussies, buggers, queens, fairies, dopers, junkies. Sick, venal. Someday a real rain’ll come and wash all this scum off the streets…
The DSM-IV-TR criterion A(4) for Schizctypal Personality Disorder, which is placed on Axis II (see next paragraph), asserts that metaphorical speech is often found in people with Schizctypal Personality Disorder. Other speech patterns that may emerge include overelaborate, circumstantial, stereotyped, and as mentioned earlier, vague (APA, 2000, p. 701; Sperry, 2003, p. 244).