Did Nidal Malik Hasan suffer from compassion fatigue or vicarious traumatization?

There are many tragic questions emerging from today’s massacre at Fort Hood.  The one I’m interested in is why a reportedly mild-mannered psychiatrist, a specialist in disaster and preventive psychiatry no less, would make the decision to open fire on his fellow soldiers.

Did Nidal Malik Hasan suffer from compassion fatigue or vicarious traumatization? One reason may be so-called compassion fatigue, also known as vicarious traumatization or secondary traumatization.

According to the Psychiatric Times, the condition is defined as “indirect exposure to trauma through a firsthand account or narrative of a traumatic event. The vivid recounting of trauma by the survivor and the clinician’s subsequent cognitive or emotional representation of that event may result in a set of symptoms and reactions that parallel PTSD (e.g., re-experiencing, avoidance and hyperarousal). Secondary traumatization is also referred to as compassion fatigue and vicarious traumatization.”

It’s certainly possible. Todd Essig, over at True/Slant, paints a vivid, plausible scenario:

Imagine every day trying to help young men and women somehow put their lives back together despite their night terrors, flashbacks, and chronic sleeplessness. While you reach out to help, they mistrust your every move and respond with hair-trigger tempers, not to mention all the physical symptoms, alienation, and hopelessness. Surrounded by thoughts of suicide–and homicide–you try and keep faith with the honor and challenge of providing care.

But soon the line between their experience and yours starts to blur until, well, something like what happened at Fort Hood today becomes an all too real possibility.

Combined with the fact that he was due to be deployed to Iraq, extremely reluctantly if reports are to be believed, we can surmise that his thought process was compounded an already fragile mental state.

But wait. That explanation may too simplistic, according to Mindy B. Mechanic, an associate professor of psychology at California State University, Fullerton. She says that such an extreme reaction, even in the setting of vicarious traumatization, is unlikely: “They might get depressed or have some emotional fallout from it, but to go on a shooting spree is not part of what happens to people from having to deal with trauma survivors all the time.”

It’s obviously too early to come up with anything conclusive. More will almost certainly come out in the ensuing days.

But if anything, this event brings much needed light to the mental health issues plaguing both soldiers, and apparently, their doctors.

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  • http://seaton-newslinks.blogspot.com/ David Seaton

    I think that you may be missing an important thing here.

    As part of his work Nidal Malik Hasan was hearing the stories of soldiers returning from combat duty in Muslim countries, where the enemy were of the same religion as he, and in the case of Iraq, of the same ethnic group as his. I would imagine that these soldiers, as part of their “therapy” would express racist and hostile attitudes toward Islam and toward Muslims and narrate in great and explicit detail the atrocities they may have committed against Muslim men and women.

    It may have been that Dr. Hasan had become radicalized by this daily bombardment and had begun to identify with the Muslim suicide bombers that his patients pursued.

    I think that this is a more probable explanation of his behavior than, “vicarious traumatization or secondary traumatization.”

  • One of the least

    NYTimes A1 photo of whom with tongue in check at the blood donation line matches the tongue in cheek gesture in the current “Dilbert” psychiatrist series

  • http://www.mind.org.uk/blog/1546 Jeff

    Readers may be startled to note what British producer Marc Munden and writer Tony Marchant have been saying about the growing of war related trauma in their 2009 documentary “Battle Scarred.”

    This has prompted mental health experts to ask: “Why is it that the military take the time to prepare our soldiers to fight but they don’t prepare them for the battle of post traumatic stress disorder when they return from the frontline?”

    Some viewers may recall what the C4′s award winning 2007 Iraq war drama “The Mark of Cain” predicted about where the pressures on British troops might lead them to.
    Indeed producer Marc Munden and writer Tony Marchant proved rather prophetic in what they foresaw and foretold two years in advance.

  • Cari

    It is VERY unfortunate that this major couldn’t have just ended his own life, but instead, he chose, yes, CHOSE to take others with him. To me, a volunteer EMT, who has seen some pretty tragic and life altering situations in my life, a very cowardly way to go.

    We must think about the families he left behind without their loved one. How do you explain to them what happened? With medical jargon and gloss over it so that you hope they may feel some compassion for the major? Sorry, if it had been my family member, I would be praying that he was burning in Hell for this.

    He was a member of the military, he got an education that others only dream about or struggle to stay afloat and pay for their education. He was paid monthly, had medical and dental and a rank that gave him respect. Where else can you go and be PAID to do your job and have all of this and more? Instead of being proud he was a coward…so no, I have no sympathy for this man, and I use that term loosely.

  • http://curbside.posterous.com Nuclear Fire

    There is a whole lot of speculation in both the post and the comment above without any proof in either.

    A patient of mine recently was tried for murder. I was amazed by all the speculation by professionals as reported in the media and blogs about his/her possible psych diagnosis. Not once did I read someone who got it right. We should be very careful about speculating on a patient we’ve not examined. Of course, if we have examined them, we shouldn’t speak due to confidentiality.

    As a combat vet, I find Mr. Seaton’s assumptions that veterans are racist and hostile towards Islam and Muslims and that they’ve commited atrocities towards “men and women” to be incredibly naive and insulting. Even the slightest bit of reading or talking to veterans and you’ll learn that the communal belief is that they’re doing something noble to help the people of the country they’re in, and that outsiders (al queda in Iraq and the Taliban in Afgan) are the enemies, not the native people (notice that most bombings aren’t against the military but against schools, police stations etc?). Those people are Muslim and practice Islam, i.e. they’re helping Muslims. Your own personal political beliefs may not agree, but it is the mindset of the soldiers that is important in this instance if you’re going to make the charge of racism, which in this instance I think says more about your biases than any soldeir’s bias.

    Being in-country you can’t help but learn to appreciated the native people and come to care about them in a way that someone reading about things in a newspaper could never understand.

    Now, if you’ll excuse me, my first consult at the VA starts in 30 minutes.

  • matt brown

    So Kevin…you too fail to even consider that his religion might possibly have something to do with it. I thought you docs were taught to start with the most obvious possibilities and work back from there.

  • Anonymous

    I think David makes a great point. I will take it a step further and question the wisdom of sending soldiers to recieve PTSD therapy from to a man that is of middle eastern descent and of the Muslim faith. I am no psych expert, but that combination seems questionable. Looking at the situation in hind sight, it seems like it would have been just a matter of time before either a patient or the Doc was pushed to far.

  • VoxRusticus

    It seems that from the emerging news stories that the alleged perpetrator was to say the least deeply conflicted about his responsibilities as a Muslim, physician and a U.S. military officer on duty in a time of war where he and others were expected to be assigned in theater in Muslim countries. I am skeptical of the vicarious trauma idea. I think it far more likely that this individual, although still high enough functioning to graduate college, medical school and complete a psychiatry residency and fellowship, that he also had significant personal failures and frustrations that undermined what may have seemed to others to be an outwardly adequate if not entirely successful professional career. The reports say he received poor professional assessments at Walter Reed. That is very significant in a small military professional community where everyone knows one another. Perplexingly, this alleged shooter spent eight years as an enlisted man, then did four years service as an undergraduate ROTC student (I think that is technically paid as an E5 enlisted), then went to the USUHS medical school which adds seven years of service to his time already accumulated from ROTC. He was a career officer, whether he liked it or not. And certainly after so much exposure to military service, he could not have been unfamiliar with its unique demands.

    I think there was something else deeply wrong with this man that was eroding his personal and private life and that was beginning to damage his professional life. The religious fanatacism was probably an accellerant but not the root problem.

  • http://neuropathologyblog.blogspot.com Brian E. Moore, MD

    There’s no way of ever knowing what went on in the mind of the shooter. That being said, the speculation and discussion regarding this case is helpful, not because it will solve this individual puzzle but because of the larger public health and public policy issues that it will bring to the fore.

  • nyc doc

    To anon commenter #7:
    I’ve treated patients from 5 continents who have been torture victims [nobody from Australia or Antartica - yet]. I’m no expert, but I ask. All doctors have treated people w/these past sorrows, but only some of us ask ab’t it. There is lots of awful PTSD out there if the doctor is open to eliciting the hx.
    I’ve had these patients rail at me b/o my white skin, privilege, etc. AND YET – my pts and I can work together b/c I deal w/it and help them to deal.
    The point is, people who hate my skin, gender, nationality, etc aren’t harmed by working with me and I am privileged to work w/them. I haven’t taken automatic weapons to anyone.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    I am the Queen of Bleeding Hearts, but I have zero sympathy for this man.

    “Vicarious traumatization”?!?! Puh-leeze. He MURDERED more than a dozen people (children, really, some of these soldiers are 18 and 19 years old) in cold blood. Wounded more than 30, people whose lives will be forever marked by his violence.

    He may have gone off the deep end, but that is no excuse. He had numerous resources literally at his fingertips to address any mental health issues he was struggling with. There is no evidence he was psychotic. Therefore he apparently willfully chose murder over healing, for himself and his patients.

    I am opposed to war in principle, but support our soldiers in their commitment and their own personal choices. I am sick over this carnage.

    I do have to add that Major Hasan’s religion and ethnic background are not considerations for me in my anger. I do believe that a sensitive, astute practitioner of the Muslim faith could be a bridge of healing to a returning traumatized soldier. A Muslim physician providing the safety and trust of an effective therapist could be a gift to a damaged soldier.

    This man has waved red flags of danger along his path for years. Dr. Hasan did the shooting, but it seems there are many others culpable as well, for not reining him in way before he became a killer.

  • nyc doc
  • ninguem

    Reminds me of that guy Naveed Afzal Haq, who shot up the Jewish Community Center in Seattle a couple years ago.

    He goes around the place shouting “I’m a Muslim American; I’m angry at Israel” as he shoots up the place. Then they look for every motive besides the one he shouted at everybody.

  • No, he did not.

    Hasan had peculiar ideas about his faith and his obligations to it over his obligations to people who did not believe as he did. He has been “disordered” in this way, or rather, unfit for military service, because of it for years. Why is was tolerated I do not know, and I hope is examined in depth.

    NPR reported his peculiar grand round topic of koranic treatment of unbelievers…beheading, oil down the throat, burning, in that order. This is his chosen method of “educating” the conferees.

    He was under investigation for at least the past six months for writing web posts about suicide bombing as a military strategy condoned in the teachings of islam.

    He told friends, colleagues and aquaintances about his beliefs that the war on terror was a war against Islam.

    You’ve heard the rest, some of it rumor, some of it direct reports… the fact is the man felt justified in murder of unbelievers who would compel him to act against his idea of what his faith demanded.

    His values were incompatible with US military service and I do not know why he was not discharged at the first demonstration of this. His refusal to be photographed with female colleagues, demand for accomodation of his non-western ideas, would have been enough for me to judge him unsuitable for such service.

  • No, he did not.

    Here’s an AP quote of a classmate of Hasan’s:

    “Dr. Val Finnell was a classmate of Hasan’s at the Uniformed Services University of the Health Sciences in Bethesda, Md. Both attended a master’s in public health program in 2007 and 2008.

    Finnell says he got to know Hasan in an environmental health class. At the end of the class, students gave presentations. Finnell says other classmates wrote on subjects such as dry cleaning chemicals and mold in homes, but Hasan’s topic was whether the war against terror was “a war against Islam.” Finnell described Hasan as a “vociferous opponent” of the terror war.

    Finnell says Hasan told classmates he was “a Muslim first and an American second.” ”

    His act was not the result of “compassion fatigue” but his beliefs.

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  • fuzzy

    The blessing is that this pitiful excuse for an officer survived to sit a court-martial by his peers.

    The pity is that, in general, he was no less competent than most of the psychiatrists I see in daily practice at the VA…people who take patient’s word that they aren’t using, who certify obviously false diagnoses and encourage patients to apply for disability and coach them on how to get it! As a nurse on the floor and in the clinics, I have seen more examples of gross incompetence from psych. people who a: are crazy—including one who ran off the floor in tears when someone questioned his orders, another who groped all the nurses, and the third example…who sat there and watched a patient turn blue without enough native sense to put some O2 on him or call a code!
    This pitiful piece of protoplasm was a killer, a coward—those soldiers were unarmed and packed into that building—but what he wasn’t and isn’t is absolved of responsibility for his actions by some obscure trumped up piece of psychiatric nonsense.

  • http://crisericson.com Cris Ericson

    Pharmaceutical salesmen give out samples; is that correct?

    How many pharmaceutical samples were in Maj. Nidal Malik Hasan’s blood or urine when he was taken into custody?

    Without surveillance footage, how accurate are eye-witness reports?

    Doesn’t the CIA have a reputation for creating this kind of scenario in order to get funding for “war” efforts? What was Maj. Hasan’s relationship with the CIA?

    On November 5, 2006, Saddam Hussein was sentenced to death by hanging. This attack occurred on the anniversary of that date.
    Was Maj. Nidal Malik Hasan a blood relative of Saddam Hussein?

  • http://seaton-newslinks.blogspot.com/ David Seaton

    I don’t know who was crazier, the shooter or the people that gave him and continued to maintain him in his assignment.

    All said, what he did was very American, he didn’t strap on an explosive belt and go for the 72 virgins, he got a gun and went on a shooting spree…. American as apple pie.

  • Lili

    Dr.Judith Orloff discusses at length the severe effects of “empath-related” physical and emotional issues. Before this is dismissed as “new age” please take a moment to check her out.

    She is an assistant clinical professor of Psychiatry at UCLA. Dr. Orloff, who comes from a family of 25 physicians, advocates “a democracy of healing,”

    The untrained individual experiences all sorts of physical and emotional responses due to watching the suffering of others. It would not be a far stretch at all for Compassion fatigue to occur in a professional trained to hear of the worst situations possible on a daily basis.

    Rage, combined with sadness, severe loss/confusion about life purpose, access to weapons, and the feeling of possible unnecessary imminent death may push anyone to disastrous behaviors. This is especially true if this man had a mental condition that was hidden due to him being in the military, or worse, because he was being exploited for other purposes.

  • tired doc

    To Fuzzy: Oh please. We are writing about the actions of a murderer and you take the opportunity to badmouth the doctors you work with. Many of us can make comments about inept nurses, but that’s not the topic here.

  • Montana

    My heart and prayers go out to all the victims family and friends.

    From all the news reports it appears this Major is a career military man and that in his current position for less than a year and was not going well. He did not want to be deployed and in fact wanted out of the Army, so he paid back his military student loans and hired an attorney.

    The reason may have been that he was being harassed and called names like “camel jockey ”. I guess all that sensitivity training for those with bigotry tendencies are all for not.

    Another reason is called PTSD by proxy, the stress of treating PTSD in other soldiers make you go a little crazy yourself. Its even more stressful because most of the higher ranks don’t even believe in such thing as PTSD. Their denial prompts them to tell suffering soldiers to “drink it off.” Some civilians in the defense dept feel the same way no doubt IMO, it’s why hardly anything is mentioned of PTSD until one of these violent episodes occurs. These people see PTSD as a cop-out or an excuse. First we need to have an understanding that PTSD actually is real before we can ever hope to help treat it (does anyone believe that being shot at or killing your fellow man is not going to affect you in some way either then or in the future?). I guess with the high soldier suicide rate before and after deployment kinda takes care of the complaints from coming in (so those who said he should have just killed himself, well that’s already happening ). What real pissed me off when I heard that the military was trying to say that some soldiers coming back from this war with PTSD or other psychological disorders had “Pre-Existing Conditions” and that the military would not pay to treat them, I think it has been corrected but what a bunch of asses they break you and don’t want to pay.

    The final issue is why does the military want to keep people in their ranks that no longer what to be there is it just sheer number? I mean is it ten percent, twenty percent. Is it that it is the only contract in the US that you can’t get out of unless to kill yourself or kill your fellow soldiers? It does not make any sense to me.

    I guess the Major could just be another wacko like Timothy McVeigh and Terry Nicholas, of course McVeigh was executed and apparently because Nicholas became Christian he received a life sentenced. I real think if he gets that far the Major will get the former not the latter.

    This is so messed up, hopefully they will make some changes that make sense.

  • http://guytanoparks.blogspot.com Guytano Parks

    With all due respect, enough with the psych crap already. Nidal Malik Hasan displayed questionable and erratic behavior and recieved a poor performance review well before his massacre of fellow soldiers. Add to that, he was a devout Muslim (conflict of interest; FIRST CLUE) and desperately tried to get out of being deployed to fight for the USA against his own kind. The blatantly obvious RED FLAG CLUES that he was unfit to serve were not recognized/addressed by the US Military and the FBI; one could deduce that they were extremely negligent in allowing for such an incident to occur. Homeland Security, I thought, is supposed to be on high alert to recognize this sort of thing. WTF?! To read details about NMH’s behavior – BLATANTLY OBVIOUS RED FLAG CLUES – Google: times online fort hood killer was devout muslim who suffered inner conflict.

  • lili

    This tiresome situation of blaming ones culture/religion as the reason a mentally ill person flips out is ridiculous.

    If a person lives in Europe their religiously extreme behaviors might differ from those of people in Asia, South America, America etc. The common factor is that they are ALL extreme murderous behaviors.

    The bottom line is that: if a person is mentally ill ANYTHING can be a trigger, anything can be “the reason”. For some it’s the war,for some it’s getting laid off/financial burdens, for some it’s almost anything.

    What happened here was that a clearly mentally ill person was allowed to flourish in the very environment he actively disliked. How the military psych evaluators missed this I do not know.

    If people continue to make it about “Islam” then go on a google mission for every mass shooting/murder and figure out something to blame. What was Columbine? Spoiled kids?

    Mental illness exacerbated in whatever way, was missed, and possibly deliberately ignored.

    Stay focused or when your next door neighbor flips his lid at Christmas and starts shooting up the neighbors (because he couldn’t afford food or presents for his family) you won’t have to bury a loved one because that person LOOKED normal. (Was a good Christian, nice fellow, professional, clean cut-all of that.)

  • lili

    Oh and one other thing. Hasan was the last suspect caught.(Remember when everyone thought he had been killed?)The other two suspects were NOT Islamic. Nor were they “brown-skinned”. They were White. So had they been coerced into “joining Islam” or were they protesting against unnecessary war?

    Could they have decided that if they were going to die it might as well be here,making a statement against the war, instead of over there,dying without mention? It may have been secondary trauma for Hasan but it might very well have been full on PTSD for the other two shooters.(Note: witnesses in the building at the time say there were “at least two shooters and possibly up to five.)

    Do google the info on the other two shooters- and the men Hasan treated-and the witnesses accounts of how many shooters were present.

    Then try again with the Islamic theory if you come to find that all of the other shooters weren’t Islamic.

  • http://schoolcrisisconsultant.blogspot.com MMCQuarterback

    He may well have had compassion fatigue, but that alone really doesn’t account for what he did. What irritates me no end is the simplicity with which this phenomenon is being treated in the media. People are talking about compassion fatigue as though either it doesn’t exist at all (as in the “puh-leeze” above) or as though it is an inevitable and uniformly homicidal reaction to trauma work. Neither is true, and the fact is we actually don’t know anything about why he did this.

    You can read my full rant on the subject here (just in case this partial rant wasn’t enough for you :-))

  • Nick

    This cannot be just a moment of rage. Killing 12-13 and wounding more than 30 requires certain determination and planning. I hope the investigation will bring up the motives of this crime, but I will not be surprised if the military will not leak them out.
    The question is: should the military have released him from service given his desire and his views as expressed in the past?

  • http://www.linkedin.com/in/achievementstrategies Marie C

    Oh, no, no, no MMCQuarterback, you totally misunderstood me. Or rather, I did not make myself clear because I was being flip.

    I have no doubt, no question at all about the existence of many forms and levels of compassion fatigue.

    What I was metaphorically rolling my eyes at was the insult rendered to people who do suffer from it. By comparing them to this man, who has been an obvious ticking time bomb for years having nothing to compassion fatigue, they are done a great disservice. Good hearted, dedicated providers experience vicarious suffering due to their empathy and diligence. They do not go on murderous rampages.

    I am embarrassed that I was so unclear and misinterpreted.

  • http://schoolcrisisconsultant.blogspot.com MMCQuarterback

    MarieC — sorry to cause you angst! I agree completely. I think sometimes we are in such a rush to be “understanding” we blow past the people who really need it and paint them with the same brush as we paint real acts of horror. Actually, in some interesting way, there’s a parallel here between the ways in which some commentators have said, “Well, of course, he was Muslim” and how some of said, “Well, of course, he had compassion fatigue.” Neither of these things cause mass murder, and innocent caring people are lumped in with those who clearly don’t know right from wrong.

  • http://www.linkedin.com/in/achievementstrategies Marie C

    MMC, exactly. I’m glad you understand.

    And don’t worry, I’m a rollicking bundle of angst under the best of circumstances. lol It takes very little to provoke a histrionic overreaction. lol

  • http://theconservativehoney.blogspot.com/ Honey

    Too bad this “compassion fatigue or vicarious traumatization” didn’t manifest itself in suicide, instead of murder.

  • Lili

    Wow it didn’t take long for this to hit mainstream


    Hasan’s Therapy: Could “Secondary Trauma” Have Driven Him to Shooting?
    By Tim McGirk

    Read more: http://www.time.com/time/nation/article/0,8599,1936407,00.html#ixzz0WKE8Ycwd

  • ninguem

    If Hasan had been a Christian Fundamentalist who shot up an abortion clinic, or a gay bar, they wouldn’t be calling it “compassion fatigue” right now.

  • lili

    ninguem November 9, 2009 at 5:18 pm

    If Hasan had been a Christian Fundamentalist who shot up an abortion clinic, or a gay bar, they wouldn’t be calling it “compassion fatigue” right now.

    Ninguem thanks for missing the point. Did the Christian fundamentalist serve as a doctor to other traumatized Christians? Was he a priest or pastor? Did he counsel gays? Where would the compassion fatigue have come from? That IS the point of the article or did you miss something?

  • ninguem

    The guy was in contact with Al Qaeda operatives. His performance record (mediocre to poor) and his scary talk about Islam is coming out, even in the left-biased media like NPR.

    “Compassion fatigue”. I’d be laughing if it werent so sad and dangerous.

  • lili

    Let’s try compassion fatigue in a different light. Your mom,sister, and nana get violently gang raped. You know every single horrific detail. Nothing is done, the convicts go free, and it eats at you constantly. Your family says YOU are to blame because you didn’t protect them. Is it funny now?

    People will always argue,evade, and use sadness and anger to avoid the bottom line:

    People are insane for whatever reason, they are dangerous, and you are not, and will never be, safe. Why? Because excuses make people safer than actual action.

  • ninguem

    You won’t even consider the possibility that his radical view of his religion had anything to do with what he did?

    >>Oh and one other thing. Hasan was the last suspect caught.(Remember when everyone thought he had been killed?)The other two suspects were NOT Islamic. Nor were they “brown-skinned”. They were White. So had they been coerced into “joining Islam” or were they protesting against unnecessary war?

    In the initial confusion, looks like they picked up two other suspects who were questioned and released. Seems they had nothing to do with the shooting, unless you have unique sources of information.

    You’re making up elaborate excuses for the guy. You’re the one jumping to conclusions.

  • lili

    I consider ALL points but I never pin one thing on a situation. If it comforts you to blame his belief in Islam go ahead BUT go out of your way to meet peaceful Islamic people or be a hypocrite.

    Surf world news. I make excuses for nothing. I jump to nothing. I just call it as I see it. People want to be “safe” by “blaming”. If it helps you sleep-do it. I cannot stop you. And you cannot stop me.

  • ninguem

    I wonder if Dr. Josef Mengele had compassion fatigue?

    Dr. Karl Brandt? (executed at Nuremburg)
    Dr. Aribert Heim? (still on the loose I believe, and by some reports converted to Islam)
    Dr. Fritz Klein? (hanged in 1945 for what he did at Bergen-Belsen)

    I could go on. All Nazi physicians. The Third Reich did not find these physicians (there are dozens more), simply by picking names at random from the German Medical Association. Most physicians refused and most were left alone, though they might not have prospered. Some LIKED what the Nazis were doing. Some people are just evil. There is a strain of Islam that is as bad as anything the Nazis believed, the only thing missing is the ability to carry it out.

  • ninguem

    I’m a physician. I work with peaceful Muslim physicians every day. They do have the common sense to realize that there is a strain of their religion that’s just plain bad news. Same as any other religion.

    I wish you had that common sense.

    The facts as they are coming in do not support your “compassion fatigue” excuse.

  • Montana

    I guess the US military will carry out detail questioning as to why he did it and will prove all of us wrong.

    After that happens, I know some will still believe there point still has some some merit.

    Interesting comments but the Nazi physicians comparison makes me believe that Ninguem is not a physician, or at least one without any comprehensive logic. Too funny.

  • Charles W Patterson

    Did I miss someone mention the most likely explanation, that this guy suffers from schizophrenia and his religious preoccupations, peculiar ideas, and behavior are simply symptoms of this disease?

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