I have been doing counseling with a girl and now young woman overseas (she lives in Germany in case you are interested)* for free for a long time now (off and on for eight years). I took her on because she seemed an emergency case.
She had seen an article about Harm Obsessions in which completely harmless people worry that they will commit violent acts, kill people, or go on a killing spree. She said she had thoughts of killing people. However, when I asked her if she resisted the thoughts, she told me no. She said sometimes she just gritted her teeth. Ok, that rules out OCD right there because the differential diagnosis was Harm OCD. If you’re not trying to stop the thoughts, forget it. It’s not OCD. It’s something else.
At age 6, she tried to murder her little brother by smothering him with a pillow. Her mother came in the room, otherwise she would have done it. Interestingly, she told me that she felt no guilt about trying to kill him and instead she thought it was funny. This got me thinking.
At age 15, she lunged at a girlfriend and tried to strangle her but pulled herself off at the last minute.
She also told me that she felt like she was the only person in the world and that everyone else was an NPC in a video game. This is the way a psychopath thinks. The narcissist thinks he’s the greatest person in the world. He acknowledges that others exist, but he just thinks they’re inferior, and he doesn’t care much about them.
The psychopath thinks he’s the only person in the world. The other people are just some sort of nonhuman objects. Being the only person in the world, there’s also some narcissism associated with psychopathy but that’s not the prominent feature. Also psychopathy has an odd self-destructive aspect to it that narcissism lacks. The narcissist is simply too great of a person to destroy himself. Why destroy the greatest person on Earth?
When psychopathy mixes with Narcissistic Personality Disorder with the addition of paranoia and sadism, you get Malignant Narcissism. This was Ted Bundy’s diagnosis. Ever notice how narcissistic he was? Other serial killers have also had this diagnosis.
Interestingly Donald Trump is also a Malignant Narcissist. So Trump has the same personality disorder as Ted Bundy! He’s just more socialized and Bundy was a lot less controlled.
Anyway the overall picture for this girl seemed to be a classic psychopath. But we can’t diagnose that in minors. Instead we diagnose Conduct Disorder, but she didn’t meet criteria for that either.
The best you could say was that she might grow up to be a psychopath. The one thing that I didn’t notice is that she did have some guilt or bad feelings about the thoughts. After all, she was worried enough about them to come to me. And as I told her what was going on with her and that it didn’t look very good from her point of view, she kept saying, “Sigh.” This implied she was not happy with her condition. I blew this off at the time, but I think it’s important.
I didn’t speak to her for a very long time until she came back at age 23. She told me that the feelings were by and large gone and anyway she had a very different attitude about them. She had guilty feelings about all manner of things.
I had no idea what she was, but she sure wasn’t a psychopath. The notion about other people being NPC’s in a video game was gone. I asked her about trying to kill her brother and her friend and how she had not cared about either incident, and she told me she didn’t remember either incident. She’s probably repressed those memories, which is interesting right there.
What was odd was that she seemed like a classic psychopath as a teenager but then aged completely out of it as an adult. This is why we do not diagnose personality disorders in adolescence. The personality changes too much. This also shows that being a fairly normal teenager with delinquent behaviors, thoughts, or feelings can completely mirror psychopathy but then vanish with adulthood, as so much delinquency does.
However, she still had these feelings. She told me that recently she ran up to a kitten and tried to strangle it, although she stopped.
She also thanked me for my “intervention” as she called it. As I said I worked with her for free because I was worried she was dangerous. She told me that without my intervention, she might have committed a violent crime, perhaps even attempted or actual homicide.
I asked her how I did it, and she said that I didn’t condemn her for the thoughts and tell her she was evil or a bad person. I had simply accepted them as a rather unfortunate part of her psyche that didn’t seem to be going away soon. Rather than trying to make the thoughts go away, which I considered a dubious exercise, I had told her to simply be “pragmatic” in her behaviors.
I told her she could think whatever she wanted to, but she needed to be careful her actions. I also said she didn’t need to act on her thoughts. Thoughts are just that: thoughts. I said I didn’t care about her thoughts. She could think about whatever she wanted to for all I cared. All I cared about was what she did.
Being pragmatic meant controlling your behaviors so you don’t do anything real stupid. I told her to think about the consequences if she acted on the thoughts. Regardless of morality, which I didn’t care much about and told her so, I told that it would simply be very, very stupid to act on one of those thoughts. So the pragmatic or smart thing to do would be to not act on them.
However, she does continue to have persistent homicidal thoughts, feelings, and urges. She doesn’t have OCD as that’s the differential diagnosis. A year ago, she became deeply depressed and went to an excellent psychiatrist in Frankfurt. The psychiatrist diagnosed Major Depression and put her on an antidepressant. She finally told her about the homicidal thoughts, and the doctor put her on an antipsychotic.
Oddly enough, the antipsychotic is making the urges go away. I have no idea why the antipsychotic is doing that as she isn’t psychotic at all.
The doctor diagnosed the homicidal thoughts as aggression stemming from Depression, but I’m not really buying it.
For one thing, other than the Major Depression she had fallen into a year ago, she had never been depressed. She suffered no depression when she tried to kill her brother or friend or kitten or when she had these feelings in high school.
Also aggression stemming from Depression looks a lot different. You are often looking at a very angry person, angry in a global sense. Even if her anger was masking depression, she would have been a very angry and mean person all those years from age 6 all the way up to age 22.
She told me that she had never felt any sort of global anger or rage towards the world, and indeed, she never seemed that way to me. Our counseling was quite noneventful and she was quite nice, kind, and cooperative. Any person with significant anger issues would have blown up at me many times by now, and I probably would left them as a client. Angry people simply are in general not very nice.
At the very least, you can see and feel the rage and hatred in them. She told me that instead she had simply felt numb like she was repressing her feelings for most of her life and suggested that this was masked depression. First of all, that’s not falsifiable, and second of all, it’s circular reasoning.
How do we know she’s depressed? Because she’s numb.
How do we know she’s numb? Because she’s depressed.
The argument is chasing its tail around the living room.
Also, the homicidal thoughts should have gone away with the antidepressant, and they didn’t. Instead, the antidepressant lifted the depression but didn’t touch the homicidal ideation. On the contrary, she needed a completely different drug for that which implies that it was a separate process.
I remain convinced that we are dealing with two separate processes here: the homicidal ideation and the Major Depression.
The problem with her is that other than Depression, there is no way to give her any kind of a psychiatric diagnosis based on those thoughts alone. Merely having those symptoms is not enough to qualify for any psychiatric disorder. You would need a number of other symptoms, and she doesn’t have them.
Psychiatrically, she’s “normal” or within the normal range, or at least she doesn’t have any diagnosable psychiatric disorder.
Her problem, which she shares with many criminals who act on these impulses, is more of right and wrong, good and bad, good and evil.
She had all sorts of other concerns revolving around alienation, worry about over-attachment to a girlfriend (she’s bisexual and in a relationship with another woman), and all sorts of other “problems in living.”
The more I listed to this stuff, the more I told her that she did not have a psychiatric problem. Instead she had the typical problems many to most people wrestle with in their lives. Hence her problems were “existential,” as in the concerns of existentialism and other philosophical schools. They could also be seen as spiritual. I advised her to go talk to a Christian preacher because she’s at least nominally a Catholic as most are in her part of the world.
If you read as many novels and short stories as I do, you will see that many characters wrestle with all sorts of symptoms of this nature. Some even take their lives. Dostoevsky of course is classic, but the interior monologues of Joyce Carol Oates or even Anais Nin are also very good, not to mention Fernando Pessoa of course. I told her to go read some of those writers and see if she could relate.
I am starting to think that a lot of our problems are philosophical and/or spiritual instead of psychiatric. Psychiatry only goes so far. We aren’t out to tell you the meaning of life, though many therapists keep writing books claiming that they unlocked the vault. And everything having to do with right and wrong, good and bad, good and evil, etc. is completely outside of the range of psychiatry. This is the purview of philosophers (especially moral philosophy), religious or spiritual leaders, and unfortunately, of law, the police, the courts and gaols.
I’m also starting to think that a lot of people who have something that looks like a psychiatric disorder are not really diagnosable as they don’t fit into any of our neat little boxes. We have to either give them some silly NOS (Not Otherwise Specified) diagnosis, which is basically a cop out, or we have to throw up our hands and say they simply don’t meet criteria for any mental disorder. Not that they’re healthy. They may well not be. But we simply don’t have a shelf to shove them into.
*She has given me permission to write this up, but I may well have changed certain things to disguise her identification.