Assessing and managing threats to commit a massacre.

Lone actor attacks like those at Port Arthur and Parklands High School Florida remain rare events though more frequent year by year. Psychiatrist are unlikely to see such killers either before or after an attack. What they do encountered on occasion are patients threatening to commit such a massacre. These threats need to be taken seriously primarily because they usually indicate significant distress but also because there is a remote chance they may try and act on the threat. Threats state an intention with the chances of enactment depending on the degree of commitment. Commitment is reflected in the level of preoccupation, plausibility, planning and preparation. Most threats have no commitment to act being an end in themselves motivated by such things as the desire to express an emotion, the wish to frighten, the attempt to manipulate others, though just occasionally they are a warning with some level of commitment to act. The assessment of threats to commit a massacre is considered in terms of the motivation and apparent commitment. Those who threaten mass killings also differ significantly from Lone Actor Attackers in their clinical pictures which further assists assessment of risk. There are some where doubts remain about the level of threat they present. The management of this group is discussed.