Category Archives: OCD

Mental Health Diagnosis: More of an Art Than a Science

A commenter writes:

How can they be “pretty damn good” and “wrong”?

Because diagnosis of mental illness is much more of an art than a science, that’s why. It’s almost impossible to get it right every time. It’s not uncommon for people to have maybe 10-15 different diagnoses. This is because psychiatric diagnosis is murderously hard. I don’t blame most clinicians for getting it wrong. It’s nothing like the diagnosis of physical illness at all.

I see a number of people with OCD who got misdiagnosed as psychotic, but that’s actually pretty common, and looking at their symptoms, I don’t blame the clinician for dx’ing them as psychotic.

When OCD is very bad, they appear psychotic, and the people I am thinking of have symptoms that appear exactly like psychotic symptoms, except they are not. They have what I call “fake delusions”, “fake illusions”, “fake hallucinations”, along with a lot of derealization and depersonalization, etc. Sometimes they can even get actual perceptual distortions, which makes things even stranger.

These people who have a form of health anxiety where they worry that they are going psychotic, and then they develop a lot of “fake psychotic” symptoms psychosomatically in the same way that patients develop fake physical symptoms psychosomatically as part of some hypochondriasis.

I know more about this stuff than the vast majority of clinicians, and I have seen more people with this problem than most clinicians will ever see. I have seen scores of people with this problem, maybe 50-75. I have gotten to the point where I can tell “Schiz OCD” (OCD with the fear of schizophrenia/psychosis theme) apart from true psychosis, but it’s not clear or easy at all if you haven’t dealt with a lot of these people. Actually it is not even easy for me sometimes.

Furthermore, in the course of diagnosing these people, you will get a few people who are actually psychotic, and you have to tell them apart from the Schiz O’ers. They are much more ill than the Schiz O’ers, but their symptoms are extremely confusing and they seem to have OCD going along concurrently with some sort of psychotic process. They are very confusing.

I don’t think mental health workers are inept, and I work in the field myself. And I do not think they are crazy at all. Most of the ones I have dealt with were amazingly sane.

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

Aggression and Violence in Mental Disorders: Extroversion and Introversion

Jason Y writes:


I think the Keifer Sutherland character could be Robert, SD even more so (no doubt), and I’m starting to doubt my sanity.

We really need to get away from this notion that mentally ill = dangerous.

It’s quite tiresome. I work in mental health, so I ought to know about this sort of thing.

Mental illnesses do not necessarily increase the rate of violence. Some like the anxiety disorders seem to actually dramatically reduce the risk of violence. In fact, if you cure someone of an anxiety disorder, their potential for aggression, violence or dangerousness statistically might get a lot higher. And if a violent person somehow got an anxiety disorder, the anxiety disorder would probably dramatically reduce their aggression and violence. There is something about that phobic type of worried and often guilty fear that seems to act like a force that actually propels people in the opposite direction of aggression and violence.

I cannot speak for other mental disorders, but I would say OCD’ers are about the farthest away that a human could possibly get from being a serial killer. If there was an absolute antithesis of a serial killer, it would be an OCD’er. And this even applies to OCD’ers when they are about as insane as they can get. There is something about the illness that makes the person quite harmless, statistically speaking anyway.

People with OCD are the least likely of any humans to ever commit any irrational violent act. Any random person, male or female, walking down the street is much more likely to commit an irrational serious violent act or homicide than an OCD’er.

People with GAD like one of our commenters are very unlikely to commit violent acts. Same applies to Panic Disorder and any of the phobias. There is something anxiety disorders that not only does not cause aggression, violence or antisocial activity but actually seems to dramatically propel the person in the opposite direction. If there was an utter antithesis of a violent or dangerous person like a psychopath, sort of like if Psychopaths were +Violent/Dangerous, then the anxiety disorders would be -Violent/Dangerous. We can think of them as “Anti-Dangerous.”


Filed under Anxiety Disorders, Crime, Mental Illness, OCD, Psychology, Psychopathology, Serial Killers

You Can’t Hide Crazy

Between 1982-1986, I was probably crazier than I have been for most of my life. The only thing that comes close is another terrible episode for maybe eight months in 1991 when I got so out there that I thought I was going psychotic.

I did have a major theme at the time. It started off a with a classic well known theme that I will not reveal, but later it morphed into all sorts of weirdness. There was war in my head between the Crazy and the Sane. They did ferocious battle  for some time. At some point, the Sane side simply surrendered and said, “Ok Crazy, you win. Do what you gotta do. We are tired of fighting you. We give.”

And then the Crazy pretty much took over and OCD had control over my life to the point where I had to do whatever nutty thing it was telling me to do. Mostly it was telling me to do things that were more or less normal behaviors.At one point, Crazy set up something called The Rules. It set these up because Sane kept being bad and breaking whatever Rule Crazy had set up. Crazy would set up some evil rule that I would have to live by. Sane was furious about the Rule, and at some point it  would try to break it and succeed.

This just made OCD mad, and it would simply come up with a new Rule. I do not want to go into the nature of these Rules too much, but one Rule was that I could not be happy. I would start enjoying myself and then the Rule would come crashing in and I would feel that I had to obey it. The Rules were very powerful, almost as if they were coming from God or better yet, a child’s parent, and I was very frightened of them and usually felt compelled to obey them due to this scary power that they had. There were lots of other Rules, but they were rather weird and I do not want to go into them right now.

But during the 80’s episode, none of the craziness was outward, though I did have a some rituals like having to tap my back pocket two or three times on occasion, especially when I went through a doorway. Actually one of the Rules was that I had to be crazy, but that the craziness had to be hidden and secret and my outward behavior had to be as normal as possible. But the rituals were nothing anyone would pick up. I tried to make my outward behavior as normal and sane as possible, and I was in school and working the whole time. I earned a teaching credential at USC while I was out of my head, and then I worked very regularly as a substitute teacher for the Los Angeles Unified School District.

I was seriously nuts the whole time I was teaching school, but it didn’t  affect my work performance because my outward behavior was quite normal.

I was also running all over LA trying to break Wilt Chamberlain’s record by screwing half of the hot women in LA, and while I never got even 1% of the way to 20,000, I still dated a lot of women and had a ton of sex.

I was seriously out of my mind while I was running around LA trying to screw every other hot chick I saw. I don’t know I managed to date so much when I was that nuts, but I somehow pulled it off. But the women all picked up that there was something wrong with me. They usually called it “anxiety.” But I rampaged through the female population of LA nonetheless, craziness being nut much of a barrier. I may have even gotten some battle wounds in the process while on sexual duty. You know, the kind that make you go to the doctor?

Women were not the only ones who caught on. And at both USC and especially while teaching, most of my colleagues and instructors caught on that there was something seriously wrong with me.

Problem is when you are not right in the head, you can act like the most normal person on Earth, and everyone will still call you nuts. That’s because if you are “secretly nuts” the way a lot of neurotics or OCD’ers are, it still shows in your eyes, on your face, and possibly in body language.

If your head is nutty, you will give off nutty nonverbal vibes, some in body language but most in the way we can sort of read people’s minds by looking at their faces, eyes, etc. A lot of “secretly crazy people” will appear distracted, disconnected, terrified, haunted, stunned, nervous, anxious, out to lunch, off in space, or on their own planet somewhere. Stares, both thousand yard and blank, are common and lead to a lot of people labeling these folks as crazy. You see a guy with a thousand yard stare, and it really doesn’t matter how normal he otherwise acts. That Nam vet stare alone will cause most folks to think he is somehow not right in the head at all.

You really can’t hide crazy.

The more mentally healthy you are inside, the saner you will appear to others. The crazier your head is, the more you are going to seem a bit nutty or “off” to others, to say the least.


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

Severe OCD: The Borderlands between Obsession and Delusion

For about eight months in 1991, from March-November, I was about as crazy as I have ever been in life. I wasn’t psychotic, but I was getting some weird perceptual alterations, and my mind had seriously gone off. On the one hand, I was painfully aware of these things. On the other hand, I was pretty convinced that I was going psychotic, mostly because of the way I felt. I got into therapy within a few months. The psychologist did go round and round a bit about whether I was psychotic or not, but he and the psychiatrist agreed after a bit that I wasn’t psychotic. He said, “The only delusion you have is that you think you’re nuts.”

When OCD gets very bad, they can appear psychotic and they often feel like they are going psychotic themselves. They often present as being either afraid they are going psychotic or convinced that they have gone psychotic. It is not not uncommon for them to get a diagnosis of psychosis or even schizophrenia. I deal with people with this type of OCD or OD theme all the time. In fact, I currently have two clients with this theme and another one is waiting in the wings. There are others I am talking to who have not signed on.

It is best described as Fear of Psychosis, but on the OCD boards they call it “Schiz OCD.” That is a misleading name, but it means that they have OCD with the Schizophrenia or Psychosis theme. That theme translates into  fear that they are schizophrenic or psychotic or that they are going to become that way soon.

I have had some OCD clients with Schiz OCD and a couple with the Harm and Pedophile themes who were all misdiagnosed as psychotic, and a few were misdiagnosed schizophrenic.

The Harm theme (Harm OCD) means they are afraid they will attack or kill other people or fear of harming others. The Pedophile theme (Pedophile OCD or POCD) is entails the fear that one is a pedophile.

Harm OCD’ers are generally completely harmless in spite of their creepy symptoms. These are simply completely harmless people who fear that they are murderers, rapists, or violent people, etc.

Pedophile OCD’ers are almost always not pedophiles at all. They are simply sexually normal people who fear that they are pedophiles. They are generally harmless to children, though I am familiar with a case where a woman with Pedophile OCD actually molested her three year old boy, though not seriously. Anyway, three year olds hardly remember anything that happened to them at that age. She was arrested and charged with child molestation, but the charges were dropped on the basis that she was in treatment. She has as whole team working with her, and the main thrust is to keep her from molesting the boy again.

Most of the psychosis diagnoses I have seen with my clients (see below for exceptions) were in error, and these folks simply had OCD. But if the clinician doesn’t understand how OCD can look like a psychosis but not be a psychosis, they might misdiagnose someone. It boils down to the difference between an obsession and a delusion. The two can be confused, and clinicians do misdiagnose obsessions as delusions. The difference can be a bit fine-tuned, but generally it is straightforward.

The problem is that many clinicians simply have no idea how to tell an obsession from a delusion. Obsessions can get unbelievably bizarre, and at first look, they can appear in content like the sort of delusions that psychotics get.

I did have two very ill people come to me, (call them Mr. A and Ms. B.), who seemed to have both OCD and schizophrenia, among other things.  It took me a while to figure out that they actually had both conditions at once as opposed to one or the other alone, and Mr. A was a diagnostic confusion for a while. But both of them did seem to have some sort of psychotic process going on. Mr. A had had a clear psychotic break around age ~19-20, and another had gone through an obvious schizophrenic prodrome in late adolescence and early adulthood.

Ms. B was hallucinating most of the time, including a lot of visuals. Mr. A also appeared to be hallucinating, as he was experiencing his thoughts being broadcast out into the environment, and he was afraid people could hear them. Both were both functioning very poorly, were on disability, and working or in school. Mr. A was living at home and had had a conservatorship set up for him. This entailed some sort of trustee who doled out the monthly SSI check Mr. A as they saw it, so Mr. A had no control over his finances. Mr. A was also in and out of the hospital on involuntary hold on a pretty regular basis.

What is odd is that both of them so lucid during our email conversations  you wondered how they could be psychotic.


Filed under Anxiety Disorders, Mental Illness, OCD, Psychology, Psychopathology, Psychotherapy

A Typical Case of Harm OCD

James writes:

Might not be the correct place to ask this, but does this look OCD-ish to you? I’ve always suffered from being a worrier as my Mum puts it. Ive been scared of getting someone pregnant from swimming near them for over 2 years despite knowing chlorine kills semen. I’ve been scared of wetting the bed before that, it’s just who I am.

But these have never been as scary as this to me. So about late September I started getting issues with my eyes, and this along with a relationship with a girl not working out led to some kind of depression.

And it was around this time I acquired a curiosity that I may be a psychopath. I like violent video games, the Walking Dead and have a dark sense of humor. This curiosity made me very nervous. I began to look online a lot at of tests and kept checking with friends and relatives to see if I was a psychopath. It was just something I kept looking up. Considering it was 4 months ago, I can’t quite remember the extent of the worries, but it was getting really scary. I asked loads of questions on forums, and it managed to keep me calm whenever I felt I was worrying to much.

It was about November 10th were I got an intrusive thought/urge of hurting my mother with a knife. I was not angry with my Mum or anything – it was just something that happened. One minute I was cutting up biscuits to take through to my family and the next I was in shock. I managed to serve up the biscuits in the lounge with the knife in an attempt to prove to myself I wouldn’t do such a thing. Is that a thing in OCD, normally people with OCD would be scared of knifes not use one to prove their a psychopath? Anyway I swiftly ran upstairs and felt the most scared I have ever felt ever in tears and upset by the fact I was thinking like this.

I discovered it may be OCD, and I told my mum all about it; she claimed it was normal. The thought never really occurred much, maybe as I was exposed to knifes and my family when washing up every night after that. However, the fear still remained strong. There was a period of time after that where I was so scared I felt I was in a dream almost detached from reality. The fear changed/adapted, and I began to obsess that I was a school shooter. Thoughts like, “I used to kill ants as a child, so that must mean I’m psycho because psychopaths are cruel to animals when they are young” and “School shooters like video games just like me”.

I looked at Wiki articles on mental illness associated with the school shooters and took online tests multiple times on separate occasions, and no matter the results, the anxiety would only go for sometime, and soon after, I was yet again convinced I was a homicidal maniac.

I would make myself be extremely nice to people. I have this thing were I check taps and stuff and do typically OCD actions to make myself feel like I have OCD, reinforcing that I’m OCD and not psycho. One of my most effective ways of getting rid of anxiety was looking at posts like this on my phone to read over when I got scared (I’ve read this loads).

Recently I have got back in to playing somewhat violent games and TV, but I still get slightly uncomfortable. January was when it got worse. I got convinced I wanted to do it. Similar to the case on the homicide above, I was convinced I wanted to do it. Let me make this clear.

I never planned to do a school shooting, and I have never bought a gun. I was really scared by that. How do I know that it is OCD and not me actually wanting to do it? I have been depressed recently possibly due to OCD. How do I know that it’s not that and that I’m actually homicidal? My doctor suggested it was anxiety. Any answers will make me happy, so go ahead. Finally thank you for your posts and such – they’re really really helpful.

EPGAH writes:

I have OCD myself, and my brain is wired differently. I think in scenarios. You might even say I plan too far ahead.

I think that’s all your brain is doing, “What if I did this?”
Something like the cartoon of Dragon’s Lair, if you’re old enough to remember that, or if not, just think of it as looking ahead in chess. It’s not so much you WANT to do that, it’s your brain is saying “What IF I did this?”

I work as an OCD counselor and see clients very much like this (but often not with this theme) almost every day, and EPGAH is 100% correct. This guy does not even want to do any of these things! Not only that, but no part of him wants to do any of these things! A general rule in psychology is “Intrusive thoughts do not represent real desires.”

So this guy is not having violent fantasies at all! He’s probably not even angry. And actually the Harm OCD’ers (that’s what he has OCD with the Harm theme) are actually the most gentle, meek, kind and nice OCD’ers of them all! This guy is suffering what I would call “irrational fears.” Why has he latched onto this theme? Because at the moment, this is biggest fear! That’s all this is – his biggest fear. It’s 100% fear and 0% anything else.

Also, if you really want to make sure someone doesn’t attack you, go hang around with one of these Harm O’ers. Not only are they generally very nice, but Harm O’ers are in the category of humans who are least likely to carry out a violent act!

Whether these people ever act on these thoughts is controversial. Some say they never do, but others say there have been a few cases. Generally they do not act on the really nasty stuff, but sometimes they act on the milder fears.

One guy had Harm O about turning his bicycle into pedestrians and cars along the side of the road. He would actually start to do it, but before he could actually do it, he would simply crash his bike.

Another man had a fear of throwing the car into reverse while driving fast down the road. Well one day he was driving along and he just did it – he threw his car into reverse!

There is an OCD theme called ROCD or Relationship OCD where the person is going round and round about whether they love their significant other (SO) anymore. It could be a spouse or a lover. There is also Gay OCD or Homosexual OCD where completely straight people fear they are either turning gay or are really gay. Bizarrely enough, there is even Straight OCD, where gay people are terrified that they are turning straight or that they are straight! I have actually seen a couple of cases of this!

The thing with OCD is that when they get really deep into it, they can become convinced that the obsession is true, even though it is 100% not true.

I have heard of Gay OCD cases where the person becomes so convinced they are gay that they actually go out and have gay sex. They usually only do this a handful of times. Of course, that doesn’t settle matters at all and in fact it tends to make them dramatically worse, even suicidal. It’s not a good idea.

I have also heard of ROCD cases where they become so convinced that they do not love their spouse or lover that they break up their marriage or end the relationship. Of course, this resolves nothing and often makes them worse.

I have personally never heard of anyone acting on a Harm OCD obsession and committing a violent act, but many of them are convinced they are going to do violent things. Some even start thinking that they have to do violent things. “I am going to have to do this violent thing,” is how the thought goes. Sometimes the OCD will egg them on and try to get them to commit the violent act and keep upping the ante on them when it doesn’t work.

Commonly, the violent urges are so strong that they say they have to “sit on their hands” to keep from lashing out and striking people. It feels as if their limbs have gone on autopilot.

The strange thing is that as weird and terrifying as Harm OCD gets, in general, they never act on any of these violent thoughts. In other words, these people are harmless, even laughably harmless.

It is often said that Harm OCD’ers never act on these thoughts, but some clinicians say there have been some cases of people acting on harm obsessions. But then again, if you take a random sample of people walking down any busy street, a certain percentage of them are going to commit a serious violent act the future, probably even in the near future. You could calculate the risk that any average person would do such a thing and come up with an odds figure of what the odds are that any given person will commit a serious violent act in the future or near future. We could assign that risk to all of us, as we are all part of the random population.

The bizarre thing though is that no one is less likely to commit a serious and irrational violent act in the future or near future than someone with Harm OCD! In other words, the illness is preposterous.

Lately there are a lot of people with the pedophile theme, Pedophile OCD or POCD. In almost all cases, these people are 0% pedophilic and have no more interest in children than you, me or anyone else. These are people who are worrying about being something that they are not!

Although it is said that POCD’ers never act on their thoughts, I have in fact met one woman who did so. She did sexual things with her 3 year old son. I do not think they were very serious, and he will probably never remember it anyway.

Somehow she got caught and was arrested and charged with child molestation. However, mental health intervened and I do not know how it happened, but charges were dropped on the demand that she be monitored by clinicians as long as the illness was present. She presently has a whole team working with her. She has not done this act any more times.

Curiously, she did not do this act for a sexual reason at all. In fact, she did it for another reason altogether which I do not have time to go into now.

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

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