Category Archives: OCD

Harm OCD Versus Other Conditions: Differential Diagnosis

This is a repost of a very popular post of mine on psychology. It just received a massive update and major changes have been made. It is offered here in case you did not read it the first time and are interested in the subject.

A very frequent complaint in OCD patients is thoughts of harm, either harming oneself or others. The general rule is that the person never acts on the thoughts, although this is somewhat controversial. Some say there have been a few cases of OCD sufferers acting on their harm obsessions. It’s just that I have personally never heard of a case.

In addition, as a counselor, I have worked with countless OCD sufferers who have this particular theme over the past eight years as they come to me for help. I haven’t met one person yet who acted on the thoughts nor have I heard of anyone who has, and I have known people who have had this theme for more than 25 years.

However, sometimes sufferers start to commit the act, but they stop before they are able to carry it out.

In one case, a man had an obsession about turning his bicycle either in parked cars and pedestrians. Sometimes he would just start to act on the obsession and turn his bicycle towards the people or cars, but every time he did this, he simply crashed his bike. No one was hurt other than himself.

Generally, people read my articles and simply self-diagnose as OCD with whatever theme they have going. 100% of the people coming to me self-diagnosing as Harm OCD were in fact suffering from that very condition.

What to look for:

Resistance: I would look first and foremost for resistance. Look at how hard the person fights the thought. The harder the person fights the thought, the more likely it is to be an obsession. In fact, I would say that thoughts that are ferociously resisted are always or almost always obsessions.

Resistance to thoughts is not commonly seen in other conditions if it is seen at all. Most persons without OCD simply do not ever try to stop or fight off their thoughts. If you ask them, they will say things like, “I only think things I want to think,” and “I don’t have unwanted thoughts.” So resistance to thoughts in people who do not have OCD is probably not common.

Although it is often said that resistance is a bad sign in OCD as it makes OCD worse, I don’t mind seeing resistance. The reason is that if a person is ferociously resisting and doing so successfully, then first of all, I am quite sure I have a case of OCD so the diagnostic conundrum is over and also I know that the the OCD is simply not that bad yet.

As OCD gets worse and worse, resistance gets harder and harder. I have talked to a number of people who have gotten to the point where the thoughts have simply taken over the person’s mind and are going all the time. They can’t resist them anymore, if they ever could. Inability to resist thoughts or thoughts that have completely taken over is a sign of a more serious case.

Ego-dystonic: The person hates the thoughts, or at least it seems as if a large part of the person hates the thoughts. The new theory is that the entire self hates the thoughts and that no part of a person wants an obsession, but this is a bit controversial. Nevertheless, this is what I believe. One  hears OCD sufferers say things like, “I hate this with every fiber of my being.” That’s a good sign when they can think like that. As the condition worsens, the person gets more and more confused about whether they like the thoughts or not or want to get rid of them or not.

In an advanced case of Harm OCD, the person will feel evil and it will seem as if they like the thoughts and do not want to get rid of them. This can cause diagnostic confusion. Feeling evil, feeling like they like the thoughts and feeling like they don’t want them to go away are all aspects of advanced Harm OCD. The key here is ego-dystonicity. These feelings cause alarm and profound anxiety in the person as they feel that they are turning evil against their will or that they are becoming something that is in opposition to their true self.

Ego-alien: The person is often confused as to why they are even thinking these thoughts. One  hears such things as, “I have thought a million times, why the Hell would I even think of this stuff even one time, ever?…I love my mother/father/husband/wife, etc. so why am I thinking about killing them?” If you ask the Harm OCD sufferer if they feel angry, they will usually say that they don’t. The person is often frankly mystified why they are even having these feelings in the first place.

Another part of the ego-alien aspect is that the person feels that the thoughts are not even really their own. They know that the thoughts are just thoughts and they know that the thoughts are coming only from themselves and not from an outside entity, but nevertheless the thoughts are so alien to the person’s identity that they often seem like they are not the person’s own thoughts.

The person’s inner voice can become split into a “sane voice” and an “OCD voice.” The OCD voice can sometimes sound like it is someone’s else’s voice other than the person’s own inner voice. Really it is just the person’s inner voice morphing into a new form. This experience is so alarming that the person often fears that they are going psychotic.

Thoughts go against the person’s morals: This is the reason for all of the distress, resistance, anxiety and alarm. The thought of hurting or killing random others or loved ones or certainly people one is not angry at all with seems profoundly wrong on at least some level to the Harm OCD sufferer because typically deep down inside the person with this theme is paradoxically enough, an extremely moral person.

And oddly enough, they are often remarkably passive and non-violent. This clashing of one’s morals is what engenders the strong resistance, discomfort, anxiety, worry, and alarm.

Differential diagnosis: There are apparently quite a few people with ego-syntonic fantasies of hurting and killing other people. Sometimes it is someone they hate, and sometimes it is anyone in general, women in general, or some particular ethnicity, race or religion in general. The major problem with thoughts of harming others is that the people who are never going to do it are often the main or only ones who show up clinically.

That is, often the only people showing up inn therapy are the Harm OCD sufferers or in other words, the only people who show up for therapy are the people who are never going to commit these acts.

The people who are really thinking seriously about hurting or killing other people or who like to think about such things it and are not bothered by these thoughts, feelings, urges or plans, and they simply do not seek help. This is a real problem: truly violent people generally simply do not show up clinically asking for help to try to stop acting on their violent urges. It would be nice if they did, but they just do not.

These people are variable. Some go through life choosing to think these violent thoughts, and sometimes it is just a phase that they give up at some point. This is often seen in an  adolescent male. In some cases of course, they act on the thoughts of harming others, and these are the people you read about in the papers.

But in many other cases, they never act on the thoughts and can go years, decades or a lifetime with frequent thoughts of harming others that are never acted on even once. For every one person running around being a serial killer, there are probably 100 more  who dream of such things but due to various controls or fears, they are able to avoid acting on their fantasies. People have more control than we think. Nobody has to do anything.

Sociopathy: This is not OCD. Sociopathy develops in childhood and adolescence and is generally a long-standing problem. A non-sociopathic person simply cannot turn into a sociopath in adulthood de novo; it’s not possible. If you’re not a sociopath by age 18, you will never be one.

An informal survey of sociopaths on an Internet forum for sociopaths revealed that most to all sociopaths said that they enjoyed thinking about harming others. A typical comment was: “Thinking about hurting or killing people is one of the few things that I actually enjoy thinking about.”

So we see that most sociopaths take great pleasure in thinking about hurting or killing people. They think about it whenever they want to. If they want to think about it, they do, and if they don’t want to think about it, they don’t. The harm thoughts are ego-syntonic. They don’t feel bad about having these sorts of thoughts. Thinking about these things is simply their idea of a good time.

Unfortunately, most sociopaths never show up in a clinician’s office. Just thinking about something is fortunately not grounds for hospitalizing someone. Anyone can fantasize about being any kind of criminal that they want to be. As long at they don’t do anything, there’s nothing that the law or psychiatry can do.

Lack of guilt: You will sometimes run across people who have violent fantasies about people they hate. This is not OCD. They will often tell you that they are not going to act on the thoughts, but the fantasies sounds like a good idea since they hate the person so much. They do not feel guilty about these thoughts; instead they enjoy them. The thoughts are not resisted. A famous psychiatrist said, “A homicidal fantasy a day keeps the psychiatrist away.”

In more florid cases such as Borderline Personality Disorder or Bipolar Disorder, the person is making overt threats and seems to be capable of carrying them out. They generally don’t act on the threat, at least not homicidally, although they often commit minor acts of impersonal violence, damage property, and are generally menacing. Obviously in some cases they do commit acts of serious violence thought. But in my experience, the overwhelming majority of homicidal threats are simply empty threats.

Nevertheless, if presented clinically, this is cause for alarm, and in the US, under the Tarsakoff Rule, persons making homicidal threats can be hospitalized for making specific threats towards a specific person. In other words, in the US, if a person says, “I feel like killing people,” there is no grounds for commitment. There’s nothing to act on.

But in the US, if a person is making a specific threat towards a certain known individual that seems to be a credible threat, clinicians have to notify the person being threatened, and the person making the threats may be legally involuntarily hospitalized, although in many cases, they are not committed, or if they are, it is only for the 1-3 day minimum.

Note that it is very hard if not impossible to determine in a clinical setting exactly who is dangerous and who is not.

Potential serial killer stopped: A recent case history along these lines in a journal is instructive. A man had Bipolar Disorder. At some point in the disorder, he developed elaborate fantasies of being a serial killer. He had assembled a very fancy murder kit, including all the implements he might need. He also had a list of ~20 people he was going to kill. He had been following and observing them for some time and had taken precise notes on many aspects of their locations, travels, and behavior. He had notebooks with elaborate plans on how he planned to kill these people.

It’s not known how or why he revealed this in therapy, but he did. The threat was considered credible enough to be actionable. He was hospitalized for 1.5 years in an institution in which he underwent intensive therapy and was given medication. At the end of the period, his fantasies and desires to be a serial killer had been completely eliminated.

The team said this was a very unusual case of successful intervention. They noted that he was not a sociopath, and this was probably the only reason that he volunteered his plans in therapy and was able to renounce and be alleviated of his desires, and return to society as a healthy member. The man had some ambivalence about his plans, and this was due to his not being a sociopath.

This was not a case of OCD.

He enjoyed his elaborate plans, had been planning them for some time, had assembled kits and stalked potential victims and had elaborate, pleasurable, long-standing and ego-syntonic fantasies about homicide which were not resisted.

A person with Harm OCD will never assemble a murder kit, write down elaborate plans for how they are going to kill people, stalk potential victims or even carry weapons. The overwhelming emotion in Harm OCD is fear, and the tremendous fear will prevent them from doing any of those things.

Harm OCD sufferers often go to great lengths to keep from acting on their thoughts. Some “disarmed” themselves before they went to see another person. They would remove all “potential weapons” from their person so they could not use them to attack the person they were with. They would also   “disarm their vehicle” when another person was getting into it. They would take all potential weapons and hide them under the seat of the car so they would not use them to attack the person.

Sexual sadism: Sexual sadism is a paraphilia that almost always develops in its strong form in childhood or adolescence. The person’s preferred means of arousal involves hurting, humiliating, degrading, insulting and abusing an other person. These are people who like to hurt other people. They get off on it sexually.

A very large number of serial killers are sexual sadists. They kill in order to get off sexually. Their masturbatory fantasies since childhood or adolescence have typically involved sadism, torture or even homicide.

It is very common for serial killers to have a history of kinky sex with their wives or lovers. The kinky sex usually involved bondage, discipline, sadism and masochism.

In addition, the severe sexual sadist may have an erotic arousal to images of women who are either dead or appear to be dead. These people, typically men, collect photos of dead bodies or women who appear to be dead.

Unfortunately, sexual sadism tends to escalate over time. There have been cases of serial killers or murderers who could only orgasm if they were pretending to strangle their wives.

A rather typical case might look like this:

A gay man with sexual sadism presents for therapy. Sadism is extremely common in the gay community. His sadistic activities have been slowly escalating over time. The last time he had sex, he burned a man with cigarettes. He got so excited that he wanted to kill the man, and he had to restrain himself from doing that. He presented to therapy thinking he was out of control. He was afraid he would kill the next man he had sex with.

This is not OCD. Fantasies in paraphilias such as sexual sadism are typically very pleasurable. The thoughts, images, feelings and urges are either seldom or never resisted. So what we look for her is an ego-syntonic syndrome with a lack of resistance. In addition, we are looking for strong sadistic sexual fantasies, typically dating from an early age, that are powerfully arousing. Such fantasies will be absent in Harm OCD.

The potentially confusing aspect of paraphilias and OCD is that while the paraphilia gives the person a great deal of sexual pleasure, and they often spend a lot of time masturbating to the paraphilic fantasies, it is rather common for them to feel strong guilt after they have an orgasm and the excitement fades. Alternately they can feel a lot of guilt about the paraphilia itself as in the case of exhibitionism, voyeurism or body part fetishes.

What is going on here is something like an addiction. Paraphilias look like addictions to drugs, alcohol, gambling or pornography. The paraphilic “addict” loves his paraphilic “high” and often feels out of control with wild pleasure almost like a roller coaster ride when they are caught up in the high of the addiction. They often describe themselves as feeling out of control in this phase.

When the drug run is over or the addict wakes up with a hangover or an empty wallet at the casino or drug party, there is a crash in which the addict feels terrible that they are so powerless over their addiction. They also feel guilty and pained that they are suffering the aftereffects of the addiction. Feelings of self-loathing are common in this phase.

However, in some very bad cases of Harm OCD, violent and sadistic thoughts about torture, murder, cannibalism etc. intrude quite often during masturbation or possibly sex. This is not sexual sadism; it is OCD. This is relatively common in Harm OCD, and the sufferers often describe it as being  extremely unpleasant. The difference here is the intrusive nature of the thoughts which are generally not present in sexual sadism, where instead of being intrusive and resisted, the thoughts are pleasant and welcomed.

On occasion, a sociopath or potential serial killer will present to someone or other, more often law enforcement than a clinician. Usually they present only once and then go away. Possibly years later, they may begin killing. In one case, one of the prime suspects for the possible Smiley Face Killer Gang presented to a police station about powerful urges to drown young men. He was afraid he was out of control, and he was going to act on them. The police could do nothing to retain him.

This is not a case of OCD.

This is a sociopathic person who simply feels out of control.

In a case in the UK, a serial killer gave a warning years before killing that he felt he was out of control and was afraid he was going to kill someone.

Once again, this is not OCD.

It’s another sociopath who fears they are losing control. This person will be having strong, long-standing ego-syntonic fantasies of homicide which are not resisted. They are pleasurable to the person, but they do not want to act on them, probably due to fear of going to prison. Over time, homicidal fantasies may become stronger so that the capacity to resist putting them into action becomes more difficult. This is what happens when these people fear they are losing control.

In short, a diagnosis of Harm OCD is relatively straightforward and should prevent few problems.

What we are looking at here is the difference between problems of fear and problems of desire. OCD is a problem of fear. These other problems are problems of desire.


Filed under Anxiety Disorders, Borderline, Crime, Law, Mental Illness, Mood Disorders, OCD, Personality Disorders, Psychology, Psychopathology, Psychotherapy, Serial Killers, Sex, Sociopathy

The Lowdown on Psychotherapy

Juliette Kochenderfer-Moore writes:

I also question why some people want to work in therapy sometimes, and the endless job titles have my head spinning.

Is a  therapist the same as a counselor? What the hell is a psychotherapist? A psychoanalyst? Are a psychologist and psychiatrist the same thing?

Seriously. Most of them seem totally bored out of their minds at what they do for a living. Why are we paying bucket loads of money to go get labeled and undergo “treatment,” of which the success rate is dubious?

Most are not bored, most therapists enjoy what they are doing, I have liked most of my therapists, and I thought most of them were very smart.

Also it can be very good money. Licensed therapists can make a lot of money.

Anyone can be a “counselor” in California. Even you can. But hardly anyone does it because realistically, who is going to pay you good money to sit there and listen to their problems?

A psychotherapist is someone with a credential – in California, either a Clinical Psychologist, a Psychiatrist, a Masters in Social Work, or a Licensed Clinical Social Worker.

A psychoanalyst practices Freudian psychoanalysis. This seems to be going out, as a lot of it has not stood up to scientific scrutiny.

A psychologist is a Clinical Psychologist. They have a PhD. Most of them are extremely good.

A psychiatrist is an MD. They are medical doctors. I don’t like them quite as much as the Clinical Psychologists. I think Clinical Psychologists actually understand psychology and the psyche better than Psychiatrists. Nowadays Psychiatrists are mostly just drug pushers. If you want drugs, you need to go to a Psychiatrist.

Therapy is costly. I think psychotherapy is a luxury good that is available only in wealthy societies. You don’t really need it, but it can really make you feel better. I am convinced that many to even most 3rd World people could benefit from psychotherapy, but their societies are too poor, so they cannot afford these things.

Labeling is generally a good idea. Only 14% of the population has a personality disorder. That’s not a lot. Most people with a PD diagnosis definitely are very difficult people at best, I assure you. I say this because I have known a number of Personality Disordered persons for decades, and they are truly impossible and infuriating human beings. There is no way on Earth that is normal behavior. It’s not acceptable to act abrasive and annoying such that you screw up your own life and that of everyone around you. That’s not a definition of mental health.

Most people with anxiety disorders really have them. If you do diagnosis properly, and you put the person on the right drug, it is amazing what you can do.

I think it is incredible just how “syndromal” a lot of these conditions are. I work with OCD people, and this is a syndrome if I ever saw one. All of these people seem like they are reading off the same script. I know them so well that I can almost spot one half a mile away blindfolded. Also I can practically crawl up around in the brains of my clients and tell them exactly what they are thinking because I know exactly how this illness makes you think.

The Personality Disorders are also very “syndromal,” often shockingly so.

Why so many mental disorders look nearly as syndromal as physical disorders is a mystery, but I think a good answer might be that of all of the possible ways of acting crazy, humans are somehow limited to a small subset of all such craziness due to the limitations of the human brain and condition. In other words, because there are only a certain number of ways to go nuts, humans tend to go nuts in very syndromal like patterns that look a lot like physical illnesses in the way they seem to come as a “package.”

Some people are so nervous that they just do not function well. Others are going round and round about other anxiety like conditions. Panic Disorder is crippling. PTSD is a very bad illness.

Depression is real. I have known some depressives who simply cannot function at all due to extreme depression. It is almost like they have a physical condition.

Bipolar disorder is as straight up syndrome, and these people are just not well. It’s not even really ok to be hypomanic. They’re not rational, they don’t act very sensibly, and the irritable ones are insufferable jerks who quarrel and fight with everyone all the time. Full blown mania is so non-adaptive that the person almost needs to be committed so they don’t completely destroy their lives during the episode.

It’s not ok to be psychotic. Psychotic people cannot function and are often a danger to themselves or others. They desperately need to be treated.

Schizophrenia is a full-blown illness in which there is something wrong with their brains.

Many of these illnesses are highly genetic, with Manic Depression and OCD showing some of the highest loadings of all, near 85%. Obviously these people simply have something wrong with their brains.

Psychotherapy is overpriced, but we are all doing therapy with each other all the time. Anytime you talk to any of your friends or loved ones about any psychological stuff they have going and try to give them advice on how to deal with it, you are doing therapy. Anytime you try to help people to live their lives better, function better, quit making dumb mistakes and stop engaging in unhealthy behavior patterns, you are doing psychotherapy.

The problem is that most people do not want to help you get over your troubles or teach you how to function better and quit doing nonadaptive things. Also therapists have a lot of training, and they are simply better than your ordinary person off the street at such things.

But really anytime you talk to a very wise person who gives you a lot of good wisdom on how to live your life, solve your problems, function better and stop doing non-adaptive things, you are basically getting psychotherapy, as the best therapists are simply very wise people who help you by sharing some of their wisdom with you.

Psychotherapy works very well, and it certainly works as well as the competition.

What is the competition?

Get better on your own? Talk to your friends and family get them to talk you out of it? Go to church? Read some books? Get a girlfriend or boyfriend? Get a better job? Move to a new area? Join a cult? Join a self-help movement? Go to the gym? Read Manosphere Blogs and learn Game?

None of that stuff works as well as psychotherapy for helping people with diagnosed proven psychological disorders. And none of it works as well as psychotherapy for even problems in living, growth work (trying to grow as a person) or deep work (trying to delve into the depths of your psyche and figure yourself out).

The only thing that works better than psychotherapy for a lot of things is drugs. These are psychiatric drugs and they do have a lot of side effects.

Really the best treatment is psychotherapy + drugs.

I deal with OCD’ers. When OCD is very bad, I feel that psychotherapy is useless. The person’s mind is just too far gone for the therapy to do any good work. It’s like banging your head into a wall. You can do the therapy over and over, but it won’t sink in because there is something wrong with your brain. Therapy with a messed up brain is like filling up the gas tank of a car with serious mechanical problems. That gas won’t get you very well (in other words, it won’t even work well) until you fix the car so it can run well enough to even use the gas in the first place. Once you fix up the car, now you can put gas in it, change the oil, check the fluids and all of that, and that’s finally useful.

On the other hand, drugs alone don’t seem to really cut it. I have found that when you are on a really good drug, you can start using all the great stuff you learned in psychotherapy, and now the therapy really starts working. The sad thing is that psychotherapy works best on a fairly healthy brain. You have to get your brain into a fairly healthy place to where the therapy can even function at all.


Filed under Anxiety Disorders, Depression, Health, Medicine, Mental Illness, Mood Disorders, OCD, Personality Disorders, Psychology, Psychopathology, Psychotherapy, Psychotic Disorders, Schizophrenia

OCD-Psychosis Borderline Cases

Lynn writes:

I’m really struggling with schiz-related OCD, and I know that for a fact. However, what I’m not sure about is whether I have schizophrenia (or maybe schizotypal personality) as well… or if it’s just the OCD, or if I might even also have factitious disorder imitating schizophrenia.

So, about me:

I first noticed OCD symptoms in myself when I was about 14, though it may have been subclinical then. It took the forms of “wanting to be a good person”, order/symmetry/pattern stuff, and the occasional vague “I need to do X or Y will go wrong somehow”. As I got older the order and symmetry faded somewhat and the “good person” got bad–for example, fears of violence to the point of feeling weapons in my hands and needing to rub them against surfaces to make sure nothing was actually there.

This later came to include an obsession with schizophrenia, but not of the “I’m afraid I have it” sort–rather, I wanted to prove I had it because that would provide an explanation for certain things wrong with me, taking the blame off of me, and subsequently I realised I could be (likely was) faking symptoms and started to obsessively examine if all my so-called symptoms were legitimate. I could be exaggerating, or outright fabricating.

On the other hand, I was the star pupil in my high school for the first two and a half years. All my teachers loved me. Then in the second semester of my junior year, I started skipping classes and forgetting assignments, gradually stopped bathing, started getting comments (sometimes concerned, sometimes angry) about how I never paid attention in class and my writing had gone from excellent to a mess of unnecessary words and long tangents…

Other students started to call me “weird” and avoid me, and those who were my friends either cut contact or pointed out as nicely as possible that my social and conversational skills were terrible and it made me really difficult to deal with. In response to all of this, I thought “eh, whatever, I don’t really care about school or friends anyway”, eventually dropped most of my classes, graduated early, and spent the next few years locked in my bedroom playing online games and watching anime.

I had a couple friends online, however, and the opportunity came to move out and stay with one of them when I was 21. I lived with her and her girlfriend (all three of us were bisexual) for a few weeks, but three things came up in that time.

First, my attention span and general awareness was next to none, and sometimes it was to the point that I would just stare at people really confused when they spoke to me, totally unable to make sense of their words.

Second, my roommates told me a few times that things I remembered them saying to me had never been said.

Third, I was convinced that the other girl was just trying to use me to pay the rent, had no intention of accommodating me as a proper roommate, and was taking incriminating pictures of me to show the police to kick me out. She did actually call the police, however, so I was probably right. She hated me. Bad. I did start to think I might be reaching a little when I accused her of stealing money out of my wallet, and I now think I was probably wrong on that, however.

I ended up moving back in with my family, and a couple months later the idea that I might have schizophrenia first crossed my mind. I thought about it off and on for months, but it seemed like a huge stretch, so I shelved it eventually.

Over the next year I would start seeing shadow bugs (like the typical shadow people, but the size of and moving like bugs), thinking people were breaking into my window at night… Move out again, fear that people were going to kidnap or rape me, that they were following me and planning to mug me, see whole crowds of people just coldly stare at me on the streets for several seconds…

And then over the next year after that, I’d move back with my family (evicted this time, for being a bad roommate–spending all day lying in bed and never doing chores), start noticing my hands looked strange, occasionally hear a voice repeating my thoughts aloud, and then…

And then my OCD landed on the subject of schizophrenia when researching why I was so lazy, and it was sort of like a million bells went off at once saying “YES HELLO PLEASE NOTICE ME, YOU HAVE STRUCK GOLD” …And then I shrugged it off again after a couple months of intense obsession.

And started thinking people I met online were actually people I already knew in the past, but using different names and ages and such… They acted so similar though! And then the obsession would hit again.

So basically, right now I’m sort of thinking I’m an immortal nonhuman being who reincarnated into this plane and various others of my kind are active here and occasionally contact me but usually just monitor me from a distance while doing their own things with human experiments and such.

But then there are like three voices (not actual voices lol) in my head saying “you are delusional”, “you are faking being delusional”, and “you are just being OCD, calm down” and I don’t know which to believe and the more I think and research the more distressed I get.

So, um… What do you think? (please don’t say “e-mail me”!)

This comment appeared on one of my articles, so I will publish it while keeping anything about the person’s identity confidential as is proper.

There is clearly a psychotic process going on here that looks very much like classic schizophrenia. Then we also have some very classic OCD going on at the same time. The OCD came on at age 14, and the schizophrenia came on 2.5 years later at age 16. It has long been known that OCD sometimes appears as the leading edge of schizophrenia. Schizophrenia often occurs ~2 years after the onset of the OCD, and the schizophrenia might have some of the same OCD symptoms, now magnified to psychotic level.

I am aware of several cases of OCD preceding schizophrenia. In two cases, the OCD appeared quite early around age 11-12 and was extremely severe during high school years to the point where they were nearly disabled. The schizophrenia then appeared at the classic age of 19-20.

In another case, OCD appeared at age 19 and then schizophrenia occurred at the classic age of 23.

This data has been interpreted to show that OCD is a risk factor for schizophrenia. This interpretation is false. First of all, most if not all people with schizophrenia are now known to have been ill from a very early age, possibly form birth. The schizophrenia is simply subclinical until the real hard symptoms hit often in late adolescence to early adulthood. If schizophrenics have had the illness since birth, OCD cannot possibly be a risk factor for schizophrenia as OCD appears later in life, often in late childhood to adolescence.

The question then is whether OCD is a risk factor the triggering of full schizophrenic symptoms in someone with subclinical schizophrenia since birth. This is uncertain, but it is probably not the case. Probably the stress of OCD is not a risk factor for triggering full blown schizophrenia either, as in the cases above, full blown OCD occurred for 2, 4, and 7-9 years before the onset of full schizophrenia. OCD is a very stressful illness. If the stress of OCD triggered schizophrenia, it would trigger it very soon after the OCD onset, not 2-9 years later. Stress as a trigger for schizophrenia is typically a serious stress where the schizophrenia occurs soon after the stress, not years later like some sort of time bomb.

In recent years, there has been discussion of something called schizo-obsessive disorder. These are cases of OCD and schizophrenia in the same person where the OCD is impacting the schizophrenia. Often these people retain more insight into their delusional processes than typical schizophrenics as OCD is a disorder of doubt whereby schizophrenic is a disorder of knowing. So the OCD can lead to better reality testing where the factor of doubt may be introduced into delusional material.

Schizo-obsessive disorder is probably just OCD and schizophrenia occurring in the same individual with different onsets for each illness. Each illness is discrete and neither one was causative or the other, yet both illnesses are impacting each other probably via an endless feedback loop whereby they feed into each other like a dog chasing its tail and sometimes it is difficult to tell where one illness ends and the other begins.

The above case looks like classic schizo-obsessive disorder. Schneiderian symptoms such as hearing ones thoughts spoken out loud are common as are ideas of reference and in particular paranoia. The prototypical “voice in the head” of OCD is often quite a loud voice, louder than in most OCD cases. In fact it is so loud that sufferers sometimes worry that others must be able to hear their thoughts. There is sometimes difficult diagnostics between a very loud OCD voice and and worrying that others can hear it, which has more of an OCD character to hearing one’s thoughts spoken aloud which is more schizophrenic..

Auditory hallucinations occur, but they are not common.

Functioning is often better than for schizophrenics. In the above case, you can see that this person has been able to move out of the parental home several times. They had to move back home, but most schizophrenics would probably be too ill to even survive living on their own for any length of time.

Delusions are often reported but are then denied as the person says that they do not really believe this. This is because these people often cannot accept being delusional. Probably what is happening is that delusional material is simply being hidden and then denied when a clinician confronts the person with it. Paranoid and grandiose delusions are common.

Insight wavers between complete loss to partial to even full insight on a spectrum where the symptoms move back and forth along the spectrum without any particular order or reason. These people may be more likely to recognize that they have schizophrenia than other schizophrenics because the presence of OCD enables improved insight. It is common for sufferers to waver between believing they have schizophrenia, insisting that they do not, being unsure whether they have it or not or saying that they have some illness other than schizophrenia to explain symptoms.

Thought disorder is often present but is less severe than in schizophrenia. Often written and spoken communications with schizo-obsessives can be quite clear and cogent whereas most schizophrenic communications typically have an odd to incoherent character abut them.

Mood symptoms are sometimes present and can take a bipolar character.

They are often highly intelligent, much more intelligent than schizophrenics. This is because OCD tends to strike more intelligent persons.

Treatment is often difficult as atypical antipsychotics often worsen the OCD, in many cases dramatically so.


Filed under Anxiety Disorders, Intelligence, Mental Illness, OCD, Psychology, Psychopathology, Psychotic Disorders, Schizophrenia

Voices and Pseudo-Voices in Psychosis and OCD: Differential Diagnosis

One of the symptoms that is nearly pathognomic of schizophrenia is hearing voices. In particular, the voices are heard with the ears (not inside your head like the voice or voices we all hear in our heads), they go quite a bit of the time (for significant periods a day to continuously), there is often more than one of them, they often comment on the person’s behavior as it is happening, they often speak about the person in the third person, and they often say bad or insulting things about the person.

Although voices can be heard in other illnesses, especially Bipolar Disorder and Major Depression, they often take on a different quality than we see with schizophrenia. In Bipolar Disorder, the voices are more fleeting than continuous, and there is often only one voice. During Psychotic Mania, the voice may as likely tell the person how special and great they are than anything else. Voices in Psychotic Depression generally do not go on all the time, are limited to a single voice, and tend to focus around themes of guilt, fatalism, serious illness, death, suicide, homicide, nonexistence and other morbid topics.

Honestly, there is nothing strange, odd or disordered about hearing the occasional voice. Many persons will experience hearing a voice or voices at rare, once in a blue moon intervals in their lives. Clinicians properly regard this as within the normal realm of human experience. It only when voices are regular, annoying, distracting, terrifying or depressing that there is a need to intervene.

People generally do not understand what it means to hear voices. Many people think that the voice inside your head is a “voice” and they confuse this with the voices heard in a psychosis. The truth is that we all have a voice or voices inside of our heads. That is called our inner voice. Nor is there anything special about having more than one voice in your head or having two voices arguing with each other in your head. In fact, it is more common than you think.

I have met many OCD sufferers who complain of “voices,” but they are always confusing their inner voice inside their head with the auditory hallucinations of psychosis.

There is a ready way to tell the difference.

Hallucinated voices are heard with your ears. If you were to hear an auditory hallucination right now and you were alone at home, the first thing you would do would be to start searching around your place for someone hiding in your residence. You might look behind the couch, under the bed, in the closet, out the window, etc.

This is because auditory hallucinations sound exactly like the voices of the humans around you that you have been hearing all of your life. You hear with them with your ears, not your head. If you could not find anyone in your place, you might start looking around for the transmitter or loudspeaker that is somehow piping the human voices into your abode. You won’t be able to find it.

You may tell other people about the voices and enlist their help in searching for the person hiding in the house. If you are in a vehicle, you might hear voices coming out of the radio. You might try to take your radio apart to find the “transmitter” inside of it. You might try to take part of your home apart, particularly the vents, to find the “speakers” (voices in residences often come out of heating vents).

I befriended a schizophrenic man once and we become very good friends. We hung out nearly every day for a year. He was always trying to enlist my help to take apart the vents in his house. He also wanted to take apart my car radio to find the transmitter in it.

Periodically, he would look up and say, “You hear that?” That is because he heard a voice. Of course, I heard nothing and I would say I heard nothing. He never believed me and he always looked at me like I was crazy. He heard the voice as clear as a bell and it seemed ridiculous that I could somehow not hear it. After a while, I got tired of fighting with him and I started making up excuses, telling him that he had bad hearing and that was why I cold not hear the voices.

He would be incredulous that I could not hear it. I started saying, “Well, I believe that you heard something coming out of the radio, but I didn’t hear anything there.” I left it an open question whether there was really a transmitter in the radio or not. This is the best way to deal with these people because they absolutely will not accept that you do not hear the voices too and they reject the notion that they are hallucinating them. Trust me when I say that debating with a psychotic person about their delusions and hallucinations is a hopeless endeavor.

Schizophrenics also hear voices in public that are much harder to figure out. For instance they might walk by a room full of a group of people and experience an auditory hallucination coming from one of the persons in the room. The voice will seem exactly as if that person said it out loud. So this is a voice placed onto the body of an existing person.

With the schizophrenic, he went with me to my doctors’ office once and as we were walking away, he hallucinated a voice coming from a man in the waiting room. The voice made it seem as if the man was accusing him of something. “There he is. He’s the one who did it!” It went something along those lines. It was so hostile that it seemed as if the man was trying to start a fight with my friend. My friend wanted very much to go back to the waiting room and have it out with the man and demand to know why he said those things to my friend. It took quite a bit of convincing to keep him from going back and challenging the man.

When the voices start putting false voices into actually existing people, this illness can get quite bizarre and disturbing as you might imagine.

In OCD, sometimes the OCD creates an alternate voice in your head that is a different voice from the voice you are used to or your inner voice. At times, more than one voice may be created. I have met OCD’ers who had all sorts of voices going in their heads all at once. Some had whole room-fulls or even stadium-fulls. Others had the sounds of various animals going in their heads. A few have who farms or menageries of animals vocalizing away inside their heads.

These people are often terrified that they are developing schizophrenia, but I reject this. Just as OCD can create a new voice in your head or change your existing one, of course it could create more than two voices or possibly an unlimited number of voices. It cannot also create animal sounds and anything else the mind wants to conjure up. I see no grounds for referring to any of these phenomena as auditory hallucinations. With the OCD voices in the head, this is a person who is simply making up the voices or sounds their own in their heads. Or the OCD is making them up, whichever way you prefer. So this is someone who is creating a lot of mental chaos for themselves apparently for the perverse purpose of tormenting themselves or making themselves upset. These head voices are much more under voluntary control than schizophrenic voices and many OCD sufferers can shut them on or off and on proper medication, they often stop altogether. Or the person learns that they are doing this to themselves on purpose and decides to stop torturing themselves.

Unfortunately, many clinicians do not seem to be able to untangle the voices of one’s own inner thoughts and auditory hallucinations. Adding to this problem is the fact that many OCD sufferers will describe their OCD thoughts as “voices.” In these cases, careful questioning should reveal that the “voices” are actually inner thoughts and not auditory hallucinations.

It is uncertain how the notion of “voices in your head” got started. Schizophrenics are said to hear “voices in their heads.” This makes no sense as we all have voices in our heads, namely our inner voice or voices. Apparently since auditory hallucinations are the creation of a person’s mind and do not exist in the environment, it could make sense to describe auditory hallucinations as voices in your head considering that the voices are originating in the mind of the hearer and not externally. However, the very phrase “voices in the head” completely confuses the situation and I think it is best to drop this psychiatrically illiterate phrase from the discourse of educated speakers on grounds that it causes unnecessary confusion.

There may be some cases where the hallucinated voices actually seem to be originating from inside the skull of the hearer. Imagine what it sounds like when a person is talking next to you. Now examine that same experience, yet the voice is emanating directly from your skull. This would be the only case where “voices in your head” would be a logical phenomenological description.

OCD sufferers, especially those with the Schizophrenic OCD theme or what sufferers have called the “Schiz OCD” variant of the illness, often say that they hear voices.

Caution is needed here. I have heard many OCD sufferers inform me that they are actually experiencing auditory hallucinations. In these cases, careful questioning will generally reveal a person who is scanning the environment in a hypervigilant way and then misinterpreting ordinary sounds in the environment as possible “voices.”

They also often report hallucinations or quasi-hallucinations during the hypnagogic period between sleep and wakefulness. Many a bizarre thing happens to ordinary persons during the hypnagogic state, so it is best not to make too much of this. The period between sleep and wakefulness is odd and dream states may spill over into wakefulness, the mind may start to run wild and thought and dream may become confused. Once again, these are hypervigilant persons with high anxiety examining their hypnagogic states for signs of psychosis. It is a good maxim that when humans go looking for something, they often find what they are looking for in one way or another.

Once hypnagogic confusion, inner voices and misinterpretations of environmental sounds are eliminated, the clinician will find that the OCD sufferer rarely if ever experiences an actual auditory hallucination.

At times, normals may even think they hear a voice. Last winter, I pulled into a drug store parking lot at 8 PM. It was dark and raining fairly hard. The rain was creating quite a bit of environmental racket. As I opened my car door, a heard a voice off in the rainy parking lot say my name, “Bob.” I looked around a bit, saw no one there, thought for a bit about what just happened, concluded that I did not have an auditory hallucination but instead misread some odd environmental sound in the rainy racket, brushed it aside, and went into the store.

The truth is that even if it was a voice, I would not worry and neither should anyone else. Hallucinated voices are quite common. 14% of the population regularly experience them, most are not psychotic and many are probably quite normal. I have told myself that if I ever start hearing schizophrenic type voices going all the time, I am going to get concerned, but in the meantime, I am not going to worry.


Filed under Anxiety Disorders, Depression, Mental Illness, Mood Disorders, OCD, Psychology, Psychopathology, Psychotherapy, Psychotic Disorders, Schizophrenia

Borderline Personality Disorder Versus Sociopathy

Herehere and lots of other places.

There are definitely some major differences, and a Borderline Personality Disorder is generally not the same thing as a sociopath, but there is also some overlap. In fact, I would say there is overlap between all of these horrific Cluster B types.

Sociopathy and BPD can occur in the same individual. One of Jeffrey Dahmer’s diagnoses was BPD with sociopathic traits, among other things.

Horrifically violent people need not be sociopaths, though they often are. Some men who slaughtered their entire families – wives and children – had such diagnoses as Obsessive Compulsive PD and Narcissistic PD.

One serial killer, a long-haul trucker who was roaming around northern California, was said to be unusual in that he was not a sociopath. This was the guy who hacked a woman’s breast off and walked into a police station with her tit in his pocket to confess. Forget his name.


Filed under Anxiety Disorders, Borderline, Crime, Mental Illness, Narcissistic, OCD, Personality Disorders, Psychology, Psychopathology, Serial Killers, Sociopathy

My Life as a Peer Counselor

SkepticDoesNotMeanHater writes:

Robert, you stated in a previous post you work as a counselor/therapist, what is your degree/certification/license and area of study/expertise? Marriage? Youth? Behavioral? Psychoanalysis? Something different?

I have no degree or certification in counseling, therapy or any such thing. But in California as in most states in the US, you do not need such a credential to be a therapist/counselor. Literally anyone can hang up their shingle and call themselves “counselor” and accept money to talk to folks about their problems, try to help them out and give them any advice they think is appropriate. I do not make much money doing this. Most I ever made was $300 in a month. I charge between $20-40/hour and get it pretty reliably. Most clients say I do a great job. I have eight paying clients at the moment.

I only work with anxiety disorders and paraphilias, and even in anxiety disorders, I mostly focus on OCD. Even within OCD, I mostly focus on Pure O obsessives. I know this illness up and down, inside and out, north to south, east to west, and every which way from Sunday. I know it better than most therapists. I have been reading about it and how to treat it for decades. Better than that, I have it myself! Clients are amazed and say, “It’s like you can look inside my brain and you know exactly how I am thinking.”

Peer counseling is a good thing, and it’s growing. Lot of folks find it pretty helpful. These people are better off working with me than with their current therapist who doesn’t understand the illness.

I work a little bit with paraphilias, but I am not as good at that.

I am now an expert at sexual orientation and am often asked to determine if someone is homosexual, bisexual or heterosexual, and I can determine that very well – better in fact, than most therapists.

I am also an expert at diagnosing pedophilia and telling it apart from misleading things that look like it but are not true fixated pedophilia.

I am often asked to determine, “Am I a pedophile or am I not one?” I am getting very good at this, and I am better than most therapists now. And yes, I have worked with two fixated pedophiles. Neither was offending, so I was able to work with them. I probably work better with non-offending pedophiles than a lot of therapists because I don’t treat them like shit like so many clinicians do.

I have also worked with fetishists, voyeurs, sadists and people with urolagnia (piss freaks), including folks who were breaking the law.

I did couples therapy with one couple where the woman was concerned that husband was homosexual or bisexual because he had some interest in sex with men. I figured out his sexual orientation very fast (pure heterosexual), then I tried to explain what I thought was going on with the guy, but couples therapy is very weird and exhausting, and I am not good at it.

Other than that, I do not work much with other stuff. I have had depressives, but I really do not know how to deal with them, and I want to throw up my hands. Suicidals baffle me and seem untreatable. I cannot work with Borderline Personality Disorders at all, had one disastrous client and never want another one. I don’t see how any clinician can work with someone so impossible. I see a lot of low self-esteem but am baffled how to deal with it, and it seems intractable.

I just tell people straight up what I am good at and if they have stuff going on that I am not good at, I just tell them.

I am not allowed to give out legal DSM diagnoses, but I can give an opinion on diagnosis. If someone has a good dx in my opinion but has never been formally given a DSM dx, I tell them to go to a clinician and get one. I send clinicians and psychiatrists tons of business – they should appreciate me.

It’s all perfectly legal in California as long as you do not falsely advertise yourself. For instance, I cannot say I am a clinical psychologist, psychiatrist, LCSW or MSW. If I give myself one of those labels, it’s against the law. I tell clients I am a peer counselor rather than a therapist because it sounds less dicky and pretentious.

People usually see me for a couple of hours and then graduate on to a credentialed clinician, psychiatrist, social worker or psychiatrist. Like I said, I give these guys mountains of business.

If you lack a credential, you are just not going to get much business. Most people will pass and go for a credentialed clinician instead.

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Filed under Anxiety Disorders, Borderline, California, Depression, Law, Mental Illness, Mood Disorders, OCD, Pedophilia, Personality Disorders, Psychology, Psychopathology, Psychotherapy, Regional, Sex, USA

The Therapy of the Pedophile

I work as a counselor and for some reason mostly with clients who are all wrapped up in the idea that they are pedophiles, and I spend time every day talking to guys about this crap, so maybe that’s why it’s on my mind, as it wouldn’t be otherwise. The overwhelming majority of them are not pedophiles, and I have to convince them of this. A lot of this involves research into this question.

There is no shame in being a pedophile anyway, and I have worked with two pedophiles clinically so far.

With one guy, the main therapy consisted of trying to get him to not chop his dick off! That’s how bad he felt! He has contacted me again, and the poor fellow has a million problems. He knows what he is and he is going to go on anti-androgen drugs to kill his sex drive rather than take the chance. I don’t really like that idea but it’s his life.

When you have a rare client who is a pedophile, it is important to get them to feel good about their sexual orientation, as it’s not their fault they got wired up that way and there’s no way to fix them. Everyone deserves a rewarding sexual life in some way. If there is some interest in adults, cultivate that to the greatest extent possible to redirect away from the kid stuff, which should be blown off as unattainable.

There are a lot of issues around offending, but the two guys I worked with were apparently not offending and I didn’t even bring it up. They both had massive guilt about their sexual orientation and that had to go. There are groups online for pedophiles (Before You Act) that I highly recommend. In fact, a pedophile who corresponds with me is very active in that group and is not offending. Many or even most pedophiles may need to be in active therapy to keep them from offending, stay away from triggers and report any kids in their lives and what that is all about.

Deal with guilt and acceptance. Some of these guys just will not accept that they got wired up that way. They have to accept it and be ok with it, and I do not care what the consequences of that are. Acceptance is mandatory because there is no way to fix them.

Deal with self-hatred, shame, suicidality and desire for self-mutilation. It’s not uncommon but it’s not helpful as they’re not getting better.

Refocus: Ascertain to the greatest degree possible the sexual orientation of the client, all down to AOA. Find out if there is any attraction to matures, and then seek to redirect fantasy to that area and away from kids as an alternative. Also called Lovemap expansion.

Sexual fantasy is ok. I have guys tell me some pretty crazy kid stuff that was running around in their heads and they were getting off to it for real. It’s hard to say, “Wow, that’s great!” but you have to be nonjudgmental and let people think about whatever they want.

Offending: A big mess and I don’t deal with it. There are people who do though and redirect the person to those people.

Self-help: Discuss pedophile groups like B4U Act and see if they can join. Point out the consequences of offending.

Define pedophilia. I get people coming to me all the time with issues around arousal or feared arousal to kids. In most cases, it looks like OCD or an anxiety disorder. I also get lots of guys coming to me terrified that they are pedophiles because they find 13-16 yr old girls attractive. I laugh at them, say, “Congratulations on being normal” and say, “Why are you in therapy for being normal?” In general, most men with attractions to girls age 13-17 are not unhealthy at all, and in fact, that you are simply proves that you are a 100% normal and healthy male.

Differential diagnosis. Most of my cases go over to OCD or an anxiety issue. Once it’s OCD, I no longer worry about the person doing anything with a kid. If they tell me they are worried about molesting a kid, I generally laugh at them. In other cases, it looks more like paranoia. I had one client who seemed to be POCD, but he had no issues around arousal to little girls. Teenage girls, ok, but Lolita doesn’t count! In teasing it all apart, it turned out that his real fear was “other people think I am a pedophile” and not any worries about being one himself. This seemed to be part of some sort of a paranoid psychosis that I didn’t understand.

People with non-preferential desires mostly don’t want help anyway, but the few that do need to be told that they are normal as most men think this way sometimes. The only difference between a normal man and a pedophile is the degree of attraction. To a normal man, that mature woman is a Prime Rib. That 10 year old girl is a cold hamburger sitting in the fridge for 2 weeks and if you take a bite, the cops come to your door and arrest you, so you throw it away and don’t bother.

The steak or the hamburger. They’re both edible, but which one are you going to eat? Which one are you going to eat?

Issues around child porn. I have a few folks who were looking at this stuff and were terrified about getting caught. I advised them to wipe the drive, shut up and quit putting that stuff on their drive in the first place. One guy was terrified that any therapist would report him to the cops for having child porn on his drive, but the law doesn’t work that way, and most therapists are not cops. I kept telling him that clinicians are not cops but he just wouldn’t listen.

I don’t care what you tell me. If you confess to murder with me, it’s as good as a confession booth. I don’t wear a badge.

There was guy on the web getting a PhD in Psychology and he said he wanted to work with pedophiles because they fascinated him. He was told that unless you work in a prison setting, you will hardly ever see a pedophile in a normal clinical setting. This is because almost all of them think there is nothing wrong with their condition. Many have stated that if there was a drug to cure it, they would not even take it because they love being a pedo so much. They are typically very happy about their orientation.

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Filed under Anxiety Disorders, Child Porn, Mental Illness, OCD, Pedophilia, Pornography, Psychology, Psychopathology, Psychotherapy, Sex

Empathy and the Lack of It

First of all, what is empathy?

Empathy is the ability to share in another person’s emotions. The capability to be happy because someone else is happy, sad because they are sad, and so on. It is closely linked to love and compassion. Guilt, too, comes from the ability of a character to put themselves in the shoes of someone they’ve hurt. In other words, if you feel guilty at all, then you are an empathetic person de facto. Empathetic people are sometimes referred to as empaths.

Many persons are deficient in empathy. In my work with OCD patients, it is common to come across an OCD’er who is worried that they lack empathy. This is most common in the Harm theme of Harm OCD, where persons often feel that they are losing their empathy, that they do not care anymore, that they do not value human lives, that they no longer feel love, etc. Although it is controversial what exactly is going on here, I doubt if the OCD’er is really lacking empathy, doesn’t care, doesn’t value human life, no longer feels love, etc. This is because the OCD’er is deeply and profoundly upset by what feels like the loss of empathy and the change into a cold, heartless monster.

The truth is that folks who lack empathy do not care, do not value the lives of others, do not feel love, etc. as a general rule are not the slightest bit bothered by the fact that they feel this way. They like to feel this way. They do not want to feel empathetic, do not want to care, do not wish to value others’ lives, do not wish to feel love, etc. I have dealt with quite a few folks like this, and believe me, they are happy as clams being ruthless motherfuckers. If you are worried about your “lack of empathy” then in all probability, you are actually quite an empathetic person. Only an empath would be pained by the appearance of the loss of such an emotion.

The person who is deficient in empathy is an interesting character. One type is evaluated below:

These characters may feel fear, but not the fear of others, regardless of the situation. This kind of guy can walk calmly through a crazed mob. For good or ill, these folks are not susceptible to social panic. The reason is that these people generally do not care what people think of them.

This is where we differentiate between a sociopath and a narcissist.

A sociopath could literally care less what you or anyone else thinks of him as your opinion has no importance.

A narcissist deeply needs the love, respect and worship of others and will do anything to get praise or accolades.

Granted many narcissists are rather sociopathic and obviously the sociopath is the ultimate narcissist. The sociopath is, to himself, literally the only person in the world or at least the only one who matters. The world does not just revolve around him; the world is him.

There is a very nasty type called the malignant narcissist or the narcissistic sociopath. They are often capable of great violence. They differ from sociopaths by their extreme vanity and conceitedness and in particular by their need to be respected and admired by others. These types do indeed care what others think. Notable malignant narcissists include Ted Bundy and Jeffrey MacDonald, the physician who killed his family.

Note that a character who lacks empathy can still be perfectly capable of cognitive empathy; that is, the ability to recognize and identify an emotion – they might not be able to share in somebody’s happiness or sadness, but they have learned well enough what happiness or sadness look like, and coupled with the lack of remorse this tends to result in a ruthlessly effective Manipulative Bastard.

These people are sometimes aware that others are bothered by what looks like their lack of empathy. In order to put on a good face and fool people into thinking that they care, they put on a display of empathy and try to mirror another’s happiness, sadness or whatever. But this is all fake, a show, a game, an act. The real feelings are just not there.


Filed under Anxiety Disorders, Mental Illness, Narcissism, Narcissistic, OCD, Personality, Personality Disorders, Psychology, Psychopathology, Sociopathy

OCD and Homicidal Thoughts

Homicidal thoughts or harming thoughts are quite common in a type of OCD called “Harm OCD.” It can get pretty bad. As a counselor and a sufferer, I have dealt with many people who had this particular type of OCD. In fact, they come to me all the time! I typically do some sort of differential diagnosis with them to make sure it’s OCD and not something more serious.

Below are some cases of obvious OCD or OCD-like thinking:

1. OK so one day me and my sister were just talking and all of a sudden I get this weird urge to choke her. I would never do that to her. I can’t even kill a bug and I’m not bi polar. This has happened again recently with my other sister, the thought just randomly occurs. If it helps I have been diagnosed with panic disorder. Please don’t be mean and say I’m a psychopath or I’m crazy. I need to know if any one else has experienced this to. Please help!

2. I do too sometimes. Sometimes while I’m driving I feel the urge to swerve into traffic. Sometimes for no reason I get the urge to choke my dog or hit her to death. (Of course I’d never do it.) It feels like you have no control over yourself. It feels like your actually about to do it but you don’t.

3. Believe it or not I’ve been through the exact same thing I had violent and sexual urges that I couldn’t control but I never hurt anyone I just always felt like I would, some specific urges I had were to drown my sister in the pool , every time I was someplace high up I would have a strong urge to jump off. I had these urges from age 10-15 and I was scared to be around people but I found out it is OCD look up OCD violent urges online.

I finally talked to somebody about it and said I was worried I would hurt somebody and they said the reason the urges don’t make me a violent dangerous person is because I’m worried about it were somebody dangerous would either not care or enjoy it.

4. i think everyone thinks these thoughts, not because you want to do them, but because your brain can think it. Its just putting yourself into a scenario, kinda like a daydream. Ive thought that way…”what if i just punched her…what if i slipped and fell and hit my head….what if i swerve into traffic??” tons of things will cross your brain…you’re human and its curiosity. I think you’re just fine. Unless you start getting the urge to actually follow through with it, or attempt it. Don’t sweat it.

5. Guys… I have that too. Sometimes ill sit and watch tv and suddenly ill have a random thought of killing my mom or hurting my dogs. Anyone in my house hold. I’m completely fine when these thoughts occur. I’m not mad, nor upset. And my family never did anything wrong to make me think such things…I would NEVER hurt anyone…

And it scared me. Sometimes i avoid certain objects i could hurt people with and i stopped watching my favorite crime shows. It all freaks me out now.. Ive asked a friend, and he has it too but not as extreme. More of a “what if” thing. He says im fine and he thinks everyone has these thoughts at one point.

Some of these folks may not even have OCD, but at any rate, all of these thoughts have an OCD-ish feel to them. It’s quite common for non-OCD’ers to get thoughts like this once in a while.

This case is more difficult:

Hello. This isn’t very easy for me to let go into the world, but I would like people’s opinions. I am on the other end of a 1.5 year bout with OCD and being terrified that I am going to indulge in homicide. Things are much better now, but yesterday at work, I got all my issues worked up in my head and at one point I genuinely wanted to indulge in homicide. I actually wanted to do it.

During that I had slight panic attacks running and of course it worries me that the curiosity of doing such an act is attractive. Now, I have read many posts here on how to self help your OCD, but this is the first time I have ever been genuinely attracted to the horrible thing I’ve been afraid of for such a long time, and that’s the difference between being afraid of intrusive thoughts and being attracted to them. Is that normal psychology for an OCD sufferer, do you think my thoughts got twisted in knots and then I deceived myself into thinking I wanted to do it, or do you think I should seek some help?

The thread goes on and on, and some folks are are telling him to go to the ER and check himself in. The guy who posted this is worried that he felt like he really wanted to do it. However, many of the OCD’ers I have dealt with have told me that they feel like they want to act on these thoughts. In every case, they were given a diagnosis of OCD by multiple clinicians. The thing is that OCD itself can make you feel like you want to do these things. It can also make you feel like you might or would enjoy them. All of this causes more panic, anxiety and attempts at thought suppression.

So if someone comes to me with classic Harm OCD stuff and then tells me that they feel like they want to act on these thoughts, I am not particularly worried. It’s probably more the OCD convincing you that you want to act on the thoughts or that you might enjoy them more than anything else.

This case is much more disturbing.

Hello, My name is Ryan. I’m 17 years old. I’m posting this here today because for quite some time i have been obsessed with murder, blood, torture, and rape. When I see someone walking down the road, my mind unconsciously comes up with random ways of torture I could try on them, I’ve been doing this since I was around 15, but now something’s changed – I feel its getting harder and harder to control, I’ve had to start journaling and drawing what I would like to do to my victims.

I feel I could take countless human lives and not stress about it. Will someone please tell me what’s wrong with the way I think? My parents told me its a stage, but I know it’s more. Just someone please try to give me insight on why this is happening.

I am honestly not sure what is going on with this guy, but one thing it is not is OCD. No way does a Harm OCD’er journal and draw pictures about torture, rape and murder. Forget that. The OCD’er would be terrified of having the thoughts in the first place, would not enjoy them at all, and would most likely viciously fight them from the first time they showed up until they went away, if they ever did.

The OCD’er doesn’t want those thoughts or feelings in his head for even one second. He would never just indulge in them for pleasure or write journals and draw pictures that delight in murder, torture and rape.

Truth is most Harm OCD’ers are so scared of their thoughts, etc. that they start avoiding all situations that might set them off, including any TV shows, movies or writing that has to do with murder, rape, torture, etc. If they watch or read something along those lines, they will feel serious anxiety and nearly have a panic attack.

In the thread, a few of them ask him questions to see if this is OCD. He says he enjoys the thoughts and feelings very much. That doesn’t sound like OCD one bit. However, he does say that he tries to resist them at times, but he can’t. Now that is very odd. But there may be occasional resistance with non-OCD stuff.

The fact that he feels like he could kill countless people without a single worry in the world is also disturbing. No way would an OCD’er feel that way.

It is interesting that a number of other commenters said that they had similar thoughts and feelings, especially when they were teenagers, and at some point, they just went away. That is very hopeful. I had assumed that once you get to the point where you are fantasizing about rape, murder and torture all the time, even to the point of doodling and journaling about your fantasies, you are pretty much gone. But apparently this is not so, and people can easily move out of this kind of thinking. That is a very good thing indeed.

The following are some cases of homicidal thinking in schizophrenia:

1. Yes but not intentional homicidal thoughts more like random ones that come in my head like if I see a bus pass by me sometimes I would have thoughts of breaking the windows with a baseball bat and screaming at the passenger or punching someone randomly passing by me but not of anger I barely get angry anymore just random thoughts.

2. Hi, I’m new here to this board. I was just curious if anyone feels these symptoms. I feel this way all the time. Whenever someone looks at me wrong. All I want to do is hurt or kill that person. I was recently hospitalized a couple months ago. I’m always scared to death. All I wanna do is crawl in to a dark room and cry. Sometimes when I’m driving I think what if I just turn the wheel and kill that jogger running.

Seriously I see a pdoc and have seen the same doc since I was a little kid. My pdoc says it’s just delusions. But it’s so real!!! I was diagnosed with paranoid sz. about 3 years ago. Does anyone feel this way? Please anyone I would love to know that I’m not alone here.

3. Hello Weenska, you most certainly are not alone. I get homicidal thoughts too. The scary thing is that they are all about killing children. You see, I work in a children’s’ hospital, and for some reason my mind is set on hurting the patients there. I get so nervous when I have to go clean a room with a patient sleeping in there.

The nurses are outside of the room sitting at the nurse’s station, and I’m alone in the room with the patient. While I’m cleaning I get evil thoughts of how I could swiftly kill the child without anyone seeing. My mind comes up with so many ways on how I could get away with it too. It’s like I’m constantly fantasizing about being a secret, mysterious child killer. Isn’t that awful?

4. I know I’m not a bad person and could never harm anyone. You’re not a bad person either. Why we get these kinds of thoughts flowing through our head is beyond me. I want you to know that whatever filthy person our minds may try and persuade us to be, that its not who we really are. 🙂

5. Princess is right, you’re definitely not alone! I have homicidal thoughts about my hubby. I don’t sleep well at night so a lot of the times I am just sitting in bed watching my hubby sleep. I would think about what it would be like to actually commit a murder. I can picture myself smashing his head in with a baseball bat, or poisoning his food, I even can see my self sneaking up on him and stabbing him in the back.

I’ve told him and at first he thought it was kinda funny, but now I can tell he’s sometimes a little edgy around me. I love him so much and I don’t want to lose him…To me, this is so much more than some kind of delusion. Its like the devil himself is tempting me. I hate feeling so sick and twisted inside. Anywho, yes I can relate. I know I’m not bad, and I will fight these thoughts off as hard as I can for as long as it takes!

6. I’ve always been a real docile person, but when I got sick I had some homicidal thoughts.

7. In 1980, I had a lot of violence in my head and I was afraid for about a week that I would get violent. It scared me and made me feel bad, but I managed to control it.

8. I get these thoughts of hurting people sometimes too. I haven’t acted on them so far.

9. I used to get terrible homicidal thoughts. There were command voices, and there were the videos/images that played in my head about terrible crimes I was committing. I have been hospitalized over 20 times, and many of these were for homicidal ideation. I would be taken to the inpatient unit and put in isolation because I could not control myself.

But after the fact when I would get re-stabilized on meds, my T told me that she did not think I had it in me to hurt another person. I have never hurt another person. I am generally very kind and calm. She wanted me in the hospital because she was afraid I would hurt myself. After I had the homicidal thoughts I would feel SO guilty about having the thoughts that I wanted to kill myself because I was such a “bad” person. But, I am not a bad person. Now I have been stable on Clozaril for 6 years, and I no longer have homicidal thoughts… ever.

10. From my perspective, It might b “normal” 2 have homicidal thoughts about some 1 I don’t like or doesn’t like me. But I have homicidal about the ppl i LUV the most! It’s like the thought pops up in my head then I got a whole bunch of cause n effect scenarios.

It could b like if i c a hammer on the table, I could bash my loved one in the head. Or it could b some insecticide, n I could add a dash of death 2 a meal. I mean yea, I been thru some bad shit, but this is just fucked up! After i realize what I just wuz thinking, then I start feeling all bad, then the potential bad endings, n it bothers me. I mean, I’m ain’t necessarily a bad dude, but damn that shit ain’t cool, feel me?

11. I get homicidal thoughts when I am deeply disturbed. I make up shit in my head on how I could kill someone and get away with it. I have really good self control, and I’m a good person, and it bothers me deeply. Most of my homicidal thoughts are about my brother though because he is clearly the Antichrist. I talked to God when I was actually planning on killing him and he stopped me. He’s a crackhead and pill popper big time and only uses my disabled mother for more crack money.

Luckily he has found a place to live so he doesn’t bang on our doors at 530 or call my phone anymore. He threatens a lot towards our family, but I can do so much more harm than he could. My father passed away in January and he was the only person who could keep him in line. The constant family feuds we’ve been having has at times caused me to the point of pure insanity. I talk about killing him openly with my family and how he just needs to die.

Of course, they’re very freaked out. I’ve always had homicidal thoughts even before schizophrenia. But they have just been getting worse about my brother. I think about killing other people sometimes, but it’s mostly my brother because he’s a piece of shit. This morning he came by again and I couldn’t sleep. I haven’t heard voices in over a week, they come and go, but this morning voices were telling me to murder someone.

12. When I read this post, I immediately remembered my early teen years, when my illness really started getting bad. I had my first hallucinations when I was about 14 or 15, and that’s when I started having thoughts of killing people. At first the thoughts were of killing people at school, like a random school shooting, and then killing myself. Then came the thoughts about killing my family members and then myself. I skipped school all the time because of it. I feel sick just typing this. I want to delete it and pretend it never happened.

This one is deeply disturbing. Some sort of homicidal thinking she had actually led to her trying to kill her brother, probably when she had schizophrenia:

I’ve had thoughts like that before too. I used to go to school with a girl who I thought was perfect. I wanted to kill her because I felt so flawed next to her. The point is, NEVER act on these impulses. Never hurt anyone or you will regret it horribly. I tried to kill my brother once and he avoided me for years (can you blame him?).

As you can see, homicidal thinking is extremely common in schizophrenia. In fact, the vast majority of schizophrenics seem to experience it at some time or other. Some of this stuff looks very OCD-ish to me. Whether it justifies an additional diagnosis of OCD or not, I have no idea. You will notice that in many cases, anti-psychotic medication specifically for schizophrenia made the thoughts go away. This implies that it was not an OCD process driving the thoughts but instead it was a schizophrenic process. If it was an OCD process, the anti-schizophrenic drugs would not have worked.

The question is how does the schizophrenic homicidal thinking above compare to the OCD-type ideation in quality? Honestly, I do not have the faintest idea.

One way it differs is that in schizophrenia it can take the form of command hallucinations ordering the person to commit violent acts. Fortunately, they do not give in to the thoughts most of the time. There is something a bit similar in OCD where the person experiences thoughts inside their head ordering them to carry out various homicidal and violent acts. The difference is that in OCD it will be a thought and in schizophrenia it will be an external voice. And in schizophrenia, there is much more likelihood that the person will act on it. The chance that a person with OCD will act on the thoughts is just about nil.

However, in schizophrenia, this thinking is much more dangerous as it regularly leads to episodes of violence. However, as you can see above, only one of the schizophrenics above ever acted on their homicidal thoughts, so in many cases, they are able to control themselves.

I have never worked with schizophrenics, and I don’t know how to deal with homicidal ideation in schizophrenia. I imagine it is a very tricky area to determine a schizophrenic with this type of thinking is dangerous or not.

People come to me after reading my articles. They are basically self-diagnosing with OCD, or they have already been diagnosed by a clinician. I have found that people are pretty good at self-diagnosis for this condition. They often write me telling me that it is as I could see inside their minds and tell them what was going on in there. All of the people who came to me with homicidal or violent thoughts had OCD so far, so I haven’t had to worry much about differential diagnosis. I did have one client who was truly homicidal, but that person was thinking in a completely different way and it wasn’t OCD driving the homicidal ideation, it was something else altogether. There wasn’t much I could do about that person either.

Unfortunately, I think most of the people who are truly dangerous are simply not going to show up for counseling or therapy. They either like to feel this way or don’t care, and they don’t see any problem with their way of thinking.


Filed under Anxiety Disorders, Mental Illness, OCD, Psychology, Psychopathology, Psychotic Disorders, Schizophrenia

Normal Guy With Irresistable Urge to Kill People

Link here, and see responses. I have written about this before. This guy is now convinced that he has OCD, specifically Harm OCD. I know Harm OCD very well as I have spoken with and worked with scores of people who have it. There is no way on Earth that this guy has Harm O. Forget it. Not possible. Harm O doesn’t work like this.

As far as what is wrong with him, I have no idea. Not all unwanted thoughts, feelings and urges are obsessions. Some might be more classified as “addictions.” We may be looking at more of an addiction here. I am also thinking, if he really doesn’t want to feel this way, why doesn’t he just knock it off? You don’t want to think about killing people? Great. Just stop doing it. It’s not that hard. That won’t work for an obsession due to the nature of obsessions, but it should work just fine for a non-obsession.

I’m a relatively normal, happy guy. I have an almost irresistible urge to kill people. What’s wrong with me?

READ FIRST/UPDATE AT THE BOTTOM: I guess I should clarify that I am definitely NOT going to kill anyone. I only want to. I know the difference between wanting something and having to have something, and have never once in my entire life actually tried to hurt anyone. The furthest my desires have ever gone is thinking about how I would go about doing it. I have never owned a weapon or thought about obtaining one outside of knowing that I would have to in my little day-dreams.

I am a normal guy in my early 20s. I work full time, I have lots of friends, people generally like me when they meet me, and I work very successfully in a people-oriented business. I care deeply about my friends and family, and I stand up for people I don’t know when I feel they’re being taken advantage of. I am of above-average intelligence, and I’ve been told by more than one person that I’m their favorite smart person because I never make anyone feel like I think I’m better than them.

I’m happy with the person I am, and I’m confident in the decisions I make on a daily basis. I don’t have any money problems that can’t be solved by budgeting for a week or two, and generally always have the time and means to pursue the things I want.

I am moderately successful with women; I’m no Casanova, but in general if I make an attempt to woo someone, they are wooed. I have recently been getting serious with a girl I’m really into. She’s smart and funny and full of life, if not a little talkative sometimes, which I find endearing.

My ambition in life is to be happy without damaging the happiness of those around me. I get along great with animals and would never intentionally hurt or kill one, and hearing stories/seeing pictures of people who torture or even just mistreat animals bother me. Something as simple as a neighbor leaving their pet out in bad weather can ruin my morning.

I don’t think I’m a psychopath or even a sociopath. I’m no more selfish than the average person, as far as I know. When I hurt people’s feelings I do everything I can to make up for it if I feel I was in the wrong, which is relatively often.

I also really, REALLY want to plan and execute a murder. Or several. Usually the first solution that pops into my head when someone is in the way of my happiness is to murder them. I’ve gone as far as learning someone’s schedule and patterns and planned a fairly thorough method of killing them and disposing of their body without getting caught. Most of the people I contemplate killing are not people that are close to me, though I do occasionally get intrusive thoughts about taking the life of friends or co-workers I genuinely get along with.

I don’t think I’ll ever go through with it, but if I did I would probably choke my victim to death with a thin, strong rope or wire of some kind. Guns don’t appeal to me and knives are messy.

The main thing stopping me from going through with it isn’t a fear of getting caught or the belief that killing is morally wrong (which I do believe, but I’m not so hypocritical that I’m going to pretend I don’t betray my morals every now and then), but a fear of what it would mean about me as a person. I don’t want to hurt anyone, I just feel like I need to sometimes.

Is there something wrong with me or are these just normal invasive thoughts? I feel like I should talk to someone but as far as I know I have my desires under control.

UPDATE: Thanks for all the feedback guys. I’m getting an equal mix of Dexter quotes, troll accusations, and suggestions to see a therapist. Rathosaur’s post here made me realize I have probably have a pretty serious form of OCD that I’ve just been managing internally for a while. I plan on talking to a therapist as soon as I find out what kind of mental coverage my insurance has. I don’t feel like I’m a dangerous person, but I also don’t like having thoughts that bother me in my own head. I really, truly appreciate the input of those who have offered help.

One thing that jumps out loud and clear in this post is the narcissism of this fellow. It is also disturbing that the only thing preventing him from acting on these fantasies – and that is what these are – fantasies – is what people will think of him if and when he gets caught. People will hate him so much that his self-esteem won’t be able to handle it. What stops him from killing is how it would affect him, not the people he kills, his victims. That is rather disturbing right there.

Posters post about how this guy is a sociopath or a psychopath, but I am not getting that. A sociopath could care less what anyone thinks of him. If he likes the idea of killing but does not do it (very common in sociopaths as many fantasize about homicide but few carry it out) it will be for reasons other than his own self-image and what others think of him, since by definition, the psychopath cares nothing about his self-image or what others think of him.

If the psychopath is not carrying out these acts, it may be because he doesn’t want to go to prison. Many psychopaths have very active antisocial fantasy lives, but they don’t engage in a whole lot of illegal activity because they don’t want to go to jail or prison. So they become “legal criminals” instead.

Here is what a poster posted about this fellow in saying he was a psychopath. Notice all checks by the narcissism stuff but almost no checks by the parasitic lifestyle stuff.

Factor 1: Personality “Aggressive narcissism”

**Glibness/superficial charm** [if he woos her, she’s usually wooed]
**Grandiose sense of self-worth** [he’s everyone’s favorite smart person]
Pathological lying
**Cunning/manipulative** [if he woos, she’s usually wooed; everyone likes him]
**Lack of remorse or guilt** [see immediately below]
Shallow affect (genuine emotion is short-lived and egocentric)
**Callousness; lack of empathy** [isn’t worried about hurting his would-be victims, but is concerned about *his* self-image if he kills]
Failure to accept responsibility for own actions

Factor 2: Case history “Socially deviant lifestyle”.

**Need for stimulation/proneness to boredom** [fantasizing about murder]
Parasitic lifestyle
**Poor behavioral control** [stalking people]
Lack of realistic long-term goals
Juvenile delinquency
Early behavior problems
Revocation of conditional release

A Harm OCD’er would never, ever, ever plot of plan to kill anyone. They would never learn anyone’s schedule in order to fantasize a plot to murder them. It doesn’t work that way!


Filed under Anxiety Disorders, Mental Illness, Narcissism, OCD, Personality, Personality Disorders, Psychology, Psychopathology, Sociopathy