The recent 21-year-old Boulder shooter, Ahmad Al Aliwi Alissa, is likely psychotic. Psychotic killer characteristics sharply contrast with those of sane killers. Uniquely, psychotic killers kill innocent strangers in volume, seemingly at random, which indicates a psychotic state. They are motivated by and act from delusional paranoia, but their precise delusions can remain undetermined. They are typically Caucasian, educated but unemployed males; they usually attack during the day, act alone, rarely try to get away, and often suicide themselves or by cop; they are not intoxicated or radicalized. They plan their attack ahead, and they may have stable, even exceptional successes prior to a sharp deterioration in behavior that includes violence and withdrawal indicative of the onset of a severe mental illness such as Bipolar, typically undiagnosed or misdiagnosed as Schizophrenia. Sane killers act with obvious motives of anger, jealousy, or profit, or out of gang-related conflicts. They frequently know their victims, attack at night, and do their best to escape; they are often intoxicated or radicalized, and can act abruptly.

Family and friends described the Boulder shooter as “the sweetest kid ever, really quiet and respectful…got along with everyone,” but by high school he had changed. These same observers reported paranoia, delusions that “people were following or chasing him…” and acts of violence. Leading up to his massacre on March 22, 2021, Mr. Alissa had planned ahead, purchasing his weapon six days before his attack, acted alone, attacked in the day, killed ten innocents at random, and apparently did not try to escape.

Understanding the motive begins with his reported paranoia and delusions that may be further confirmed by law enforcement’s ongoing pursuit of his mental status and reviews of his interactions, conversations, and behaviors during the period prior to the incident. Further motive enlightenment is informed by diagnostic histories from other psychotic mass murderers with core characteristics in common with the Boulder shooter. There are hundreds of such cases but focus here is on five.

Stephen Paddock murdered 58 and wounded over 500 from his suite on the 32nd floor of the plush Mandalay Bay Hotel in Las Vegas in 2017. Aaron Alexis killed 12 at the Navy Yard, Washington, D.C., in 2013. James Holmes, dressed as the Joker, killed 12 at the midnight opening of the new Batman movie in Aurora, CO, in 2012. Jared Lee Loughner shot 19 at Congresswoman Giffords’ political rally in Tucson, 2011. Seung-Hui Cho killed 30 fellow students at Virginia Tech in 2007.

Like the Boulder shooter’s fear-inducing behavior, Mr. Cho’s and Mr. Loughner’s classmates found them menacing and feared for their own safety, compatible with irritable mania. Paranoia and delusional grandiosity are revealed by the slaughter of multiple innocent strangers and are consistent with if not diagnostic of psychotic mania that defines Bipolar.

Further examples of grandiosity are demonstrated by Mr. Cho’s saying that he had vacationed with Vladimir Putin and sending reems of disorganized written materials to NBC threatening President George W. Bush. Mr. Alexi had DOD security clearance and a high-level Navy contract position, had past episodes of violent assaults, did not sleep for several days, and called the police several times to complain that the Navy was “keeping him awake and harassing him by sending vibrations through [his hotel] walls with a microwave machine that was targeting his brain.” The fact that he believed this paranoid delusion is evidenced by his having changed hotels three days in a row, surely in hopes of escaping the Navy’s microwaves.

An example of outstanding premorbid accomplishments in a psychotic manic mass murderer was demonstrated by Mr. Holmes. He was a Phi Beta Kappa graduate and was enrolled in a PhD program in neuroscience at the University of Colorado Medical College in Aurora, CO, but dropped out due to the onset of a psychotic mental illness characterized by delusional grandiosity involving Batman. Mr. Loughner’s childhood was stable but by his mid-teens, his behavior had deteriorated. Before his attack, he was described by his father as out of control, and he may not have slept the night before his rampage. At the site of his massacre, he was hyperactive, even frenzied, euphoric, and grandiose since he was assaulting a US Congressperson. The media described his ambush as follows: “Mr. Loughner kept up his fatal barrage, dancing up and down excitedly, turning from Ms. Giffords before firing, apparently indiscriminately, at her constituents, staff, and the random passers-by.”

The Boulder shooter’s profile matches many of the descriptions of these five prior mass murderers, most of whom were misdiagnosed either before or after the crime by mental health professionals as having Schizophrenia rather than psychotic Bipolar. Diagnostic confusion occurs because some in the mental health field have not recognized that grandiosity, delusional paranoia, psychotic thinking, hyperactivity, insomnia, and mood instability all determine psychotic mania. The Boulder investigation is ongoing with regard to diagnosis.

A correct diagnosis when there is the opportunity gives a chance for efforts at treatment and prevention. Psychosis is the most important predictor of violence including suicide, murder, and mass murder. Psychosis is a symptom of a disease of the brain; it is not a disease in itself. Psychotic mania accounts for the motivations of these mass murderers. Prevention is critical as the numbers of innocent victims are substantial and growing. Correct diagnosis and treatment serve prevention. Between March 16 and April 15, 2021, there have been at least 45 mass murders that include the Boulder shooter (Madeline Holcombe, CNN, April 16, 2021). Some of these are likely also by psychotic manic killers.

Such events are not new. A description of what was surely was a classic cycling psychotic manic mass murderer some 2,000 years ago is found in the writings of Aretaeus of Cappodocia: “The patient who previously was gay, euphoric, and hyperactive suddenly has a tendency to melancholy; he becomes, at the end of the attack, languid, sad, taciturn, he complains. about his future, he feels ashamed. When the depressive phase is over, such patients go back to being gay, they laugh, they joke, they sing, they show off in public with crowned heads as if they were returning victorious from the games; sometimes they laugh and dance all day and all night.” In serious forms of mania, called furor, the patient “sometimes kills and slaughters the servants; in less severe forms, he often exalts himself: without being cultivated he says he is a philosopher… and the incompetent [say they are] good artisans. Others yet are suspicious and they feel that they are being persecuted, for which reasons they are irascible.”

The mounting numbers of mass murders by manic psychotic killers is a call to action for Academic Psychiatry to increase attention to severe mood disorders in both the classroom and clinical settings. Support for increased education and vigilance around psychotic Bipolar Disorders is warranted. The NIMH has an opportunity, if not an obligation, to lead such an effort by funding academic efforts to increase such emphasis on identifying and treating severe Bipolar patients who may be at risk for violence.

Ray Lake, MD, PhD. is the author of Bipolar (9780128192566). This extensive discussion details characteristics of Bipolar, enhancing recognition and correct diagnosis; it helps with patient acceptance and outlines comprehensive treatment. The book presents 14 figures, 69 tables, and 111 case summaries; some of the cases involve mass murders, familicide, and filicide.

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