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Dear Dr. Robert Saltzman,

I believe I have the potential to be a serial killer. Please allow me to briefly explain.

Ever since I was a baby, I was diagnosed with communicating hydrocephalus. I have had a number of brain surgeries throughout my life. Two when I was under a year old, one when I was 14 and two more at the age of 22. This last one was due to a brain infection that came due to a cut above my shunt. The cut allowed bacteria to get in and I had to have brain surgery and undergo physical therapy to relearn to use my left hand and re-develop my coordination.

I have always had outbursts growing up, but after this last brain infection, it seems they have gotten more violent. For example, I once threw my mother through a door and pulled an air rifle on her when she wouldn't get out of my face. She would constantly nag me. Another time, I took my family hostage, so to speak, while holding a knife, telling them if they called the police, I was going to slaughter them. For the most part, though, each time, I would have deep regret after the episode. There's also a small tiny voice inside that tells me to "stop", but it seems to have weakened after my last brain surgery.

I have never been close to my mother. In fact, I am 25 and still live in the same house, because, due to my disabilities, she has sheltered me. I did move out twice, but I ended up back here. My father has more or less taken a withdrawn role and has allowed it.

My psychiatrist said he thinks I have frontal lobe syndrome. I made a recent visit to a hospital and they found lesions on my frontal lobe. They recommended me to my physician. My physician wasn't so sure and put me on Prozac and said a month from now, he's going to put me on ADHD meds. He said I have suffered from many of these issues as a child (and he's right), but lately they seem much worse. In fact, after a recent fight with my ex-girlfriend (which prompted this email) and only being on the Prozac for a week (which seems to make me happy), I'm writing this email because while I am definitely a lot more productive than I have ever been in my life, I'm wondering if the medicine might be impairing my judgment. I did not feel sadness when I hurt my girlfriend (only happiness), even though I wanted to.

I have made stages to try to break free of my codependent relationship with her and have a healthy one, but it seems I still make some impulsive decisions even while being sedated on the Prozac. I'm wondering if there might indeed be a lesion on my brain that is causing this and if lesions are ever removed? I would do anything, because I honestly fear I'm going to hurt someone. I have always had a love for people and I want this dark side out of me, if at all possible.

I look forward to your response. If you could, please withhold my name.

ask dr-robert


First of all, I am sorry for your suffering. I can well understand how painful and difficult all this must have been for you, and I hear the depth of your concerns about possibly causing harm to another human being. The incidents you detailed are extremely worrisome, so I am glad you wrote to me, and happy to respond.

I am not a medical doctor, and so do I not want to guess about whether a brain lesion could be responsible for the recent strengthening of your hostile emotional states. Obviously, any insult to the brain has the potential to eventuate in some forms of altered perceptions or altered moods, and damage to areas like the frontal lobe, the hypothalamus and the limbic system is suspected of contributing to aggression, loss of control, loss of judgment, and violence*, but whether frontal lobe syndrome is the cause of your violent moods and threatening outbursts, or at least if a brain lesion is weakening your sense of self-control, I have no way to ascertain or even to opine. However, based on your report of always having had outbursts growing up, I suspect that frontal lobe syndrome is not the whole story, and that you require ongoing supportive psychotherapy in addition to medication. Medication may alter mood--hopefully, but not always, in the right direction--but popping pills offers no emotional support (such as this reply from me) whatsoever. To put this another way, I surmise that your present treatment protocol is not adequate; if it were, why would you be writing to me?

As to whether Prozac could be impairing your judgment, I can offer a bit more: yes, in my experience that can happen, and must be discussed seriously both with your psychiatrist and your physician, along with your fears about possible homicidal behavior, which also must be reported to them both. If those doctors refuse to take your concerns seriously, and if they do not come up with a workable plan for giving you more help and emotional support, then I suggest looking for a new team right away.

I worry a bit too about the ADHD medication which may very well act to alter mood states, perhaps in directions which will not be helpful to you in hearing that voice that says, "Stop!" This is something which also must be discussed with your doctors, preferably, I my opinion, before you begin taking it.

In any case, as you well understand, you must take whatever steps necessary to avoid involving yourself in violence and murder, even if that should mean voluntary commitment to a hospital where your medication can be properly selected and patiently adjusted while you are monitored carefully, where someone will be available at all times to hear your concerns, and where the frontal lobe syndrome hypothesis can be fully investigated. A short but intensive stay in such a facility could help immensely. In fact, expert and carefully designed treatment might very well be the one safety net to keep you from falling into a enormous mistake: a sudden, out-of-control action which would haunt you for the rest of your life.

In other words, I suggest that you first discuss candidly and fully your fears and concerns with both of your present doctors. If, after putting all your cards on the table—including your fears about your potential to be a serial killer—your doctors do not devise a better, more comprehensive plan to help you in managing your emotions, I suggest you check into the best possible psychiatric facility in your area for further testing and evaluation.

I hope this helps, and I urge you to move forward immediately to implement my suggestions.

Be well.

ask dr-robert

Thanks doctor.

I've been looking into neuroplasticity. Do you think something like that could help alongside the psychiatric treatment?

ask dr-robert

Hi, again, and you are welcome--

As I usually understand the term "neuroplasticity," it does not refer to a treatment, but to the natural tendency of the brain to add brain cells (neurons), and to strengthen and rearrange the connections among neurons. This ability to add and rearrange provides the substrate for learning, memory, motor control, emotional development, and adaptation to experience. In other words, the plasticity of the brain—its capacity to be molded--allows the brain to change from second to second in response to outside stimuli, and this constant changing of the brain landscape is the means by which the brain takes those stimuli into account.

Now one implication of neuroplasticity is the possibility that a damaged brain, particularly one in which the damage was acquired after birth, might be able to continue various functions in other ways, usually by moving the function to a different area of the brain—one that is not damaged. Previously, this ability to move functions to undamaged areas had been considered a natural process which happened more or less well on its own assuming that the patient received sufficient outside stimulation and emotional support, but recent research has suggested that various more focused interventions might encourage and accelerate that form of healing adaptation.

For example, Dr. Paul Bach-y-Rita experimented with allowing previously blind people to be able to "see" by means of vibrators stimulating parts of their skin in accordance with the details of a camera image [Ponti et al. Genesis of Neuronal and Glial Progenitors in the Cerebellar Cortex of Peripuberal and Adult Rabbits. PLoS ONE, 2008; 3 (6): e2366 DOI: 10.1371/journal.pone.0002366]. Eventually, the patients in this study were able to recognize a famous supermodel. In other words, areas of the skin took over as information receptors for areas of the retina, and the brain was able to interpret those signals as a kind of seeing, leading Bach-y-Rita to say, "We see with our brains, not with our eyes."

More recent experimenters--Bach-y-Rita died in 2006--have been working along the lines of assisting brain plasticity with small, implantable neuro-prosthetic devices. Perhaps it is to this kind of research that you refer. I am not well-versed in this area, and so really cannot tell you how far along science has come in developing techniques which could be applied clinically to your situation. If you continue to pursue that avenue, please let me know if you find something promising.

Be well.

ask dr-robert


* As these are some of the hallmarks of antisocial personality disorder, it seems plausible, and some research indicates that the problematic behaviors and lack of self-control of some psychopaths, sociopaths, and antisocial types originate in brain abnormalities, either congenital or acquired. The reader of this article may be interested in visiting some "ask dr-robert" pages which address psychopathy or sociopathy:

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