Psychiatric Clinic in Haile plantation, USA
Received Date: May 06, 2018; Accepted Date: June 04, 2018; Published Date: June 08, 2018
Citation: Liu J (2018) A mental portrait. Clin Psychiatry Vol.4 No.1:4. doi:10.21767/2471-9854.100052
Copyright: © 2018 Liu J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Las Vegas shooting, the deadliest shooting in the history of the U.S., has puzzled the public. The gunman committed no prior violence, he had no history of mental health issues, and there was no terrorist connection. It wasn’t for revenge and he didn’t have an issue adjusting to culture. So, what was his motive? Only several months later, another shooting happened in Parkland Florida. The gunman there reportedly said, “I want to be a professional school shooter”.
At the same time, I’m seeing a special patient who is desperately in need for help. He struggles daily fighting the urge for destruction. When I asked him about the shooting, his answer was, “I don’t know his age, but it’s not easy to hold the thought this long; it has to get out.” We have discussed the reason behind his wanting to do harm multiple times during the course. He doesn’t have any; it’s just an urge, a pleasure seeing destruction. And he has been fighting it all along.
There are concerns to diagnose him with antisocial personality disorder because he is actively seeking help. No one can detect people's thoughts inside their minds. DSM diagnostic criteria for antisocial personality disorder was trying to find as close as they can to identify people with potential harm by describing their possible behaviour patterns [1,2]. Antisocial personality disorder is diagnosed only when they have lack of self-control or deficits in executive function. This makes it easy to turn thoughts into behaviour without thinking about the consequences. Yet my patient has the judgement not to violate the law as well as intelligence to still satisfy his urge without being caught. Although the thought of chasing by the police excites him, he hasn’t yet allowed himself into that situation. His good executive function is protecting him from becoming a criminal. Although he can’t even remember how many animals he tortured and killed growing up. This would make him a great research candidate both for finding the pathology of antisocial personality disorder and mechanism self-control system, which he is struggling to maintain. Also, he does not object to the idea and is amazingly frank about himself.
He came to my once with a complaint of inability to feel love when his girlfriend at the time loved him so much. He, later, broke up with her and he does it as a rule: as soon as he can’t find anything new in his girlfriends he would abandon them. He has been promiscuous as only when he sees his partners’ response during sexual intercourse that he has a glimpse of love and intimacy as he feels real. He feels connected to people when he has sex with them, or the people he hurt and the thought of it made him want to do it more. He otherwise feels bored and nothing would interest him. He knows that his parents love him, but he is not comfortable with the love as they don’t know him; they blame on themselves for his thoughts.
Sometimes he sleeps all day for fear of doing bad things. He isn't afraid of going to prison, but he worries about his reputation that he has built for so long. Yet at times he states basically nothing holds him back. He feels like it’s his destiny and ‘meant to do’. He feels irritated daily from trying to contain the thoughts and feeling lonely as he can’t share it with anyone. He denies specific person that he wants to hurt and usually able to contain his impulse with the help of meds. He enjoys the intelligence he needs to do harm. He has watched a lot of videos of prisoner’s confession and Identified himself with them. He denies any sexual arousal from the thought of violence. He denies depression or anxiety. He denies ever been bullied or abused. He denies history of traumatic brain injury. He reports good self-esteem. He denies past manic episodes. He denies past traumatic events. There are no signs of psychosis or ADHD. He reports that he had therapy in the past by therapist and previous psychiatrists but although he acknowledges everything it didn't change his thoughts besides medications. He appears to be acknowledging most coping skills. He denies previous admissions or suicide attempts. He denies any legal issues whatsoever.
He is successful in his work and was just invited to give a talk to a youth program. He loves to read philosophy and has written things but never tried to publish them although people who read it thought it’s ‘original and creative’. States his interests in piano and writing didn’t take away the urge to destroy. He has given people money (one time $600) as he doesn’t ‘care about the money’ but it didn’t give him any joy.
He reported difficulty with social cues just like people with autism. He felt a difference compared to his peers as he was somewhat awkward even where to put his hands. He suffered from since he was 4-5 years old to high school. But he managed to learn it and by high school he was pretty good at acting as normal although not in his mind. He learned social expectations for him and can act when he needs to; although sometimes it is easier than others.
Just like people who have mental disorders like bipolar or ADHD, they tend to self-medicate. He reports daily drinking since 2014 but denies any drugs including bodybuilding agents, cocaine, or THC. At the time he was not using any meds he was drinking more to compensate for it. He used Demerol twice feeling peaceful and content afterward but denies using it again.
We talked about Gandhi who is the opposite of him. It would be much easier to be a philanthropist acting on the love and the pleasure to do so than it is his trying not to do harm when the pleasure comes from doing harm. The question is: how do we help them?
A good thing about him is he is always willing to try medication and compliant with it. He expressed strong desire to change and be well doesn't care about side effects at all as he doesn't expect himself to live long. He failed Prozac, Wellbutrin, Remeron, Clonidine, Depakote, Lithium, Tegretol, and ACEI . He benefited from Seroquel and Zyprexa for better impulse control.
Then in one session, he reports that he was given Vyvanse once when he must drive for long distance and he feels good as he would focus on ‘good things instead of evil’. So, I thought Abilify may help him more as it has the partial dopamine agonist effect. He took it for the whole month but didn’t feel any change in his dark thoughts. It made him feel ‘fuzzy and dull’. Attempted to use Vyvanse was not approved by his Insurance. He was started on Adderall XR and reports he can focus on the positives, calmer and more tolerant of irritating behaviour. States thoughts are there but the desire and appetite for it have gone. Hypothetically the pathology would be that he lacks the dopamine which also explains the novelty-seeking behaviour.
It’s easier and simple to call the thoughts ‘evil’ but it won’t help anything. This is a disorder with a pathology which we haven’t yet found. We know sometimes tumour (Glioblastoma like in the case of Charles Whitman  may cause it although that would be secondary disorder caused by a medical condition. If tumours could cause the pathological change people could be born with the pathology due to similar genetic variation [5,6]. Of course, there are people who kill out of revenge or steal due to poverty which would confound criminal psychology, but you cannot neglect that it can be a mental disorder that needs treatment. I also saw a patient who suffered from the urge to steal even though he didn’t need to. And what about the serial killers?
There could be a lot of people in our society suffering lonely from this disorder and the shooters and killers might just be the tip of the iceberg. They are out there on their own. Yet they can be disastrous if they unleash the thoughts like we all know. Promoting awareness would facilitate more people to get help and prevent tragedy from happening in the first place.
Compares to people who have suicidal thoughts, they are more lonely and helpless as the society won’t accept the thoughts. It would be helpful to let them know that it’s a disorder that needs help as they are truly suffering. But we don’t see a lot of antisocial personality people asking for help. It up to us to reach out to those people who are struggling. We may set up hotline just like the ones for suicide to have someone to talk to and relieve the inner tension. If the past shooters or killers got help before their rampage, then history could be so different.
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