wellingtongoose (wellingtongoose) wrote,

Walking Nightmares for Medical Students: Mycroft on the Examination Couch

Mycroft Holmes is sinister; it’s part of his appeal as much as the three piece suit and umbrella. His morally ambiguous actions, subtle but terrifying threats and secret power have made many people question whether Mycroft is the psychopath/sociopath in the Holmes Family.

I explore what psychopathy actually is, the different manifestations of the disease and put Mycroft through a hypothetical psychiatrist’s evaluation to see whether he would actually be diagnosed with a personality disorder.

Reblog if you like it

(If you have read part 1 – some of the psychiatric principles will be familiar to you. However I attempt to explain in more detail some of the things that I only glossed over in part 1. If you feel this is repetitive skip to Hypothetically he’s the other kind of psychopath)

What is a Personality Disorder?

The terms sociopath, psychopath and anti-social personality disorder have been thrown around Sherlock Fandom without many people actually understanding that they really are.

Firstly, psychiatrists no longer use the term sociopathy because there was no general consensus on how sociopathy differed from psychopathy. Most of the time these worlds are used to describe the same syndrome. It was never really accepted into medical terminology to be begin with and all psychiatrist using ICD-10 manual (that is everyone in the world part from the Americans) happily stopped using the term decades ago.

Secondly, anti-social personality disorder has been mentioned by many fans who did some research into sociopathy/psychopathy probably via Wikipedia. Kudos to you for trying. Unfortunately, neither Sherlock nor Mycroft could ever be diagnosed with ASPD, not unless they decided to travel all the way to America for a psychiatric evaluation.

The UK, like most of the world, uses the ICD-10 diagnostic manual for the diagnosis of psychiatric illness and ASPD does not exist. Instead we have a slightly different personality disorder: Dissocial Personality Disorder. It can be viewed as an equivalent to ASPD but the diagnostic criteria and process as very different.

But does anyone know what a personality disorder actually is? It’s a fairly important bit of knowledge if you want to diagnose someone with this disorder.

Personality disorders are enduring (starting in childhood or adolescence and continuing to adulthood), persistent and pervasive disorders of inner experience and behaviour that cause distress or significant impairment in social functioning. Personality problems manifest as problems in cognition(ways of perceiving and thinking about self and others), affect (range, intensity and appropriateness of emotional response) and behaviour (interpersonal functioning, occupational and social functioning, and impulse control). “ – Oxford Handbook of Psychiatry.

Note the important of enduring, persistent and pervasive: everyone has bad days (including John Watson) but intermittent displays of traits/behaviours associated with a personality disorder does equate to a diagnosis.

What is Dissocial Personality Disorder?

In my previous discussion, I have already stated that psychiatrists, at least those in the UK, in general do not accept psychopathy/sociopathy as a completely separate diagnosis from “Dissocial Personality Disorder (ICD-10)” which is described as “a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.” Psychopathy is treated a sub-diagnosis and a severe form of the Dissocial Personality Disorder.

The root cause of DPD is widely accepted as the innate lack of conscience and empathy.

The development of DPD has a large genetic component (identical twins are more likely to both have the disease than non-identical twins). However it is not a genetically inherited disease like colour-blindness - the environment is also important. Unfortunately the environmental triggers take effect very early in life (it is believed within the first year). By the time a diagnosis is made there is no treatment possible – the patient’s brain is already hardwired in the DPD fashion.  

We are evolutionarily hard-wired to go through life believing that everyone thinks as we do, feels emotions like we do, have desires like we do. This is the only way our brains can navigate the complex social interactions we perform every day. Loss of this perception ability leads to autism/Asperger’s syndrome. However this assumption is what makes it so difficult to fully comprehend the extent of DPD.

People who suffer from DPD actually have organic brain structure and functional differences to people who do not. They are neurologically “hard-wired differently” to the rest of the population, to the extent that one psychiatrist describes them as “aliens wearing human skin.” Their whole mode of thinking, feeling, interacting with other people is so different; people who do not suffer the condition are unable to imagine how they think.  

It has been demonstrated via brain imagining that the limbic system of people who suffer from DPD does not activate to the same extent as “normal” people when present with horribly mutilated bodies. We have an inbuilt, hard-wired emotional response to the sight of other people in severe pain. This reaction can overflow to include animals, cartoon characters and anything cute and cuddly if we are conditioned to so by society.

DPD sufferers do not have this emotional response – they are not scared and disgusted, they are fascinated.

The Psychopath Test

Psychiatrists who work with the most dangerous criminals acknowledge that a subset of people with DPD display more severe antisocial characteristics. This is where the Hare Checklist for Psychopathy (PCL) is used to identifying the subgroup of DPD who are generally more dangerous and unpredictable than their counterparts. The term psychopath is used with great caution by psychiatrists in the UK and they generally refrain from labelling their patients as psychopaths even if they score high enough on the PCL to qualify.

Portrait of a very ill man

Forget the glamorous image that Sherlock gives to sociopaths – the vast majority of DPD sufferers live terrible lives. The latest studies have shown that the condition cuts on average 15 years off their life expectancies.

This is not just because many DPD sufferers are born into socially and economically deprived families but also because this personality disorder prevents suffers from functioning well in normal society. In effect they make complete wrecks of their lives – they cannot hold down a steady job, most have extensive criminal records and many end up spending most of their lives in prison (25% of the prison population meet the criteria for DPD). Their personal lives usually consist of a long string of short broken relationships and promiscuous sexual behaviour.

Delinquent behaviour, impulsivity and no realistic long term goals are hallmarks of DPD which contribute to their slide down the socio-economical ladder. As all personality disorders are incurable, stable and persistent: DPD sufferers simply cannot make the changes that would enable them to climb out of their personal poverty trap. There is a movement within the psychiatric community to stop people with DPD from being labelled as vicious criminals and for people recognise the condition as a devastating illness.

Whatever you might think of Mycroft Holmes – he doesn’t sound like the typical DPD suffer.

Hypothetically speaking – he’s the other kind of “psychopath”.

However like any psychiatric disorder your innate intelligence (g factor),personality and upbringing all have a big effect on how symptoms of DPD manifest. There is hypothetically speaking another kind of typical DPD suffer quite distinct from the ruined lives we usually see. These suffers are highly intelligent and frequently successful socio-economically. They can be business leaders, politician, clergy etc. Such suffers enjoy wielding the immense political/economic power they accumulate and these individuals, although incredibly rare, can do catastrophic amounts of damage to the human race.

Unfortunately due to their privileged positions within society, psychiatrists can never get the jurisdiction to actually contain/treat these people. Generally they are slightly harder to diagnose but the same criteria apply – it merely takes more digging into their history, interviewing relatives and persistent evaluation. It does not take long to peel away the mask of sanity even in those who are adept at disguising the true extent of their personality disorder.

Hypothetically if Mycroft did have DPD, he would belong this group of DPD suffers. Mycroft is clearly intelligent, well educated and from a privilege back ground.  His circumstances would be enough to cushion his early displays of anti-social behaviour. This is certainly the case with many of the undiagnosed DPD suffers within business and politics.

 In children DPD manifests as conduct disorder and features an interesting classic triad of bed-wetting, cruelty to animals and fire-starting. Children who display this triad before age 15 have a very high chance of being diagnosed with DPD as adults.

I imagine with Mycroft’s privileged background, his misdemeanours could easily be covered up and no official records would ever document his petty crimes. His manners and social training would have easily smoothed over the other DPD traits such as impulsivity, irresponsibility and poor behaviour controls. Traits such as glibness and superficial charm could be cultivated to produce a much more convincing facade of normality.

Certainly many of the top businessmen and political leaders throughout history have displayed DPD traits. Mycroft’s job is not allocated by lottery. To reach the shadowy heights of power Mycroft inhabits you really need to be both ruthless and opportunistic: two traits which DPD suffers have in abundance.

With a certain amount of intelligence, it is simple to pass oneself off as normal enough and with no conscience or empathy there is only the ruthless desire to succeed. There is nothing holding such people back – no moral or emotional obligations, no weakness that can be exploited. They would think nothing of robbing millions of people of their lifesavings, or murdering millions of people to retain power.

Hypothetically, because DPD has a large genetic component, if Mycroft suffers from DPD there is a much higher chance of Sherlock also suffering from DPD (about 50% more than normal) and vice versa. Both their parents would also be more likely to have DPD, which raises interesting scenarios of the Holmes’ brother’s childhood.

From an evolutionary point of view DPD in the general population decreases life-expectancy and reproductive prospects but DPD in intelligent individuals with the circumstances can be an evolutionary gift. It greatly increases their chances of climbing up the socio-economic ladder giving them a better chance to pass on their genes. This may explain why DPD is such a prevalent condition within the general population. It is believed that 1% of all people have this personality disorder, compared to the rates of breast cancer which is only 80 per 100,000 of the population.

DPD may go some way to explaining how Mycroft got his job at a relatively young age but we must be careful not to fall into the medical student trap. Students in their desperation to get a diagnosis often like to tar every patient with the same brush – if they are in the Liver Unit, they must have a liver problem. Sadly this is not how reality works.  

Many DPD sufferers may inhabit the corridors of power but it doesn’t mean that everyone in power is an undiagnosed psychopath.

Mycroft on the Examination Couch:

BBC Mycroft is not the omniscient, overweight and rather lightly sketched character in the original ACD version. However even over 100 year ago (and many pounds heavier), he still had a massive fan base. His mystique, eccentricity and indolent genius appealed to a great many readers.

It is only in the BBC version that we actually see a more sinister side to Mycroft. His actual job is shrouded in mystery but all the times we have seen him – he has wielded immense power whilst nonchalant swinging his umbrella. He misappropriates government fund to spy on his own brother. (Although, I’m sure if anyone cared to audit his department they would be presented with several very good reasons for the level 3 surveillance). He brainstorms ways to foil international terrorism and has the authority to barter away a good deal of our national GDP when things go awry.

If we are going to actually diagnose Mycroft with something – we need to approach him just like a real patient.

Taking a History:

Psychiatry is not all about meeting criteria and ticking boxes; the psychiatric history is the important tool for diagnosis – far more important than any diagnostic manual. In a straight forwards case we can interview the patient themselves. Unfortunately a diagnostic session with a psychiatrist may only last an hour and that is never enough time to accurately assess someone’s personality.

Therefore doctors usually consult family, friends and other members of the patient’s community. This can be a very difficult task because feelings can run high, people may refuse to talk and when they do they can be unreliable.

We are missing the most important piece of information in Mycroft’s psychiatric history: his childhood. As I’ve said before DPD first manifests in childhood and the signs are the most recognisable because children have not yet learnt how to disguise their flaws. We do not know if he ever exhibited the McDonald Triad: animal cruelty, bed-wetting and fire-starting. We also don’t whether he has a criminal record.

(I do have many theories on Mycroft’s childhood but they are in part 3 of this series)

 Additionally, we would be hard pressed to actually find someone who knows Mycroft very well and is willing to take about him. From what we can see he has only a superficial professional relationship with his associates and a flawed relationship with his younger brother.

 However we do have had the chance to observe some symptoms:

  • Cunning and manipulative
  • Ruthless
  • Superficial charm
  • Undisturbed by what any average person would consider gruesome (remember his expression when he’s looking at Irene Adler’s bashed in doppelganger?)
  • Controlling and intimidating behaviour

These characteristics are typically seen in most DPD sufferers, particularly the failure to be disturbed by gruesome stuff. However none of these characteristics are actually personality traits; Mycroft isn’t all of these things all of the time. There are many beautiful moments when we see someone completely different.

Additionally none of these traits actually appear in the diagnostic criteria for DPD. Why? Because they basically describe such a large proportion of the population, psychiatrists would be compelled to label millions of very nasty people with a mental disorder when they are just very nasty.

So let’s have a look at the actual diagnostic criteria for DPD:

ICD-10 Dissocial personality disorder diagnostic criteria (paraphrased by Wikipedia)

You need to have at least 3 of the following personality traits to be diagnosed:

  • Callous unconcern for the feelings of others He shows concern for Sherlock’s feelings after Irene dies – even makes sure John doesn’t leave his brother’s side.
  • Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations - If anyone is a stickler for social rules and obligations it’s Mycroft Holmes. He goes out of his way to fulfil is obligation to Sherlock as a brother.
  • Incapacity to maintain enduring relationships, though having no difficulty in establishing them – this one is tricky, he appears to have establish good working relationships with Harry the Equerry, Anthea and even John. We are however shown that he is alone at Christmas
  • Very low tolerance to frustration and a low threshold for discharge of aggression, including violence – Mycroft demonstrates far too much self control.
  • Incapacity to experience guilt or to profit from experience, particularly punishment – it’s difficult to gage how much Mycroft feels guilt. There are many interpretations of Mycroft’s last scene with John in the TRF, he certainly looks convincingly remorseful. Additionally he fully takes the blame for exposing Sherlock to Irene Adler in front of both participants.
  • Markedly prone to blame others or to offer plausible rationalizations for the behaviour that has brought the person into conflict with society – If anything, Mycroft appears to take far more responsibility for Sherlock’s actions than Sherlock does. Certainly we never hear him lamenting about how the world has done him a great injustice.

Any psychiatrist would be hard pushed to diagnose Mycroft Holmes with DPD given that he only at best ticks one box out of six.

The Difficulty of Diagnosis

Sadly plenty of people in the world will tick 1,2 or even 3 of the diagnostic list. To get ahead in the ruthless world of business, politics or even medicine many of these traits are incredibly help.

However psychiatrists are very cautious about labelling people with this personality disorder even when they fulfil the criteria. It is very easy to acquire a distorted view of a patient particularly when we let our own prejudices muddle our impartiality.

On my psychiatric attachment, one particular patient had been diagnosed with DPD over ten years ago but when we reviewed him at a routine appointment and actually took the time to delve into his past history, the doctor had to remove the diagnosis. This particularly patient had a difficult upbringing and was exposed to criminal gangs from a young age – many of the things he did were out of ignorance and a lack of guidance than an actual personality disorder.

It is very difficult to separate the effects of later societal conditioning from the true organic manifestations of DPD for many psychiatrists.

For example: Mycroft’s nonchalant expression when viewing a batter corpse can easily be due to later conditioning as either part of his upbringing or his job. Medical students often undergo a rapid phase of desensitisation to gruesome “stuff”, which is good for the patient because you don’t want your doctor cowering in a corner when you’ve been serious injured.

A Fun thing to think about on Halloween

To leave on a sinister note - despite the evidence we see to the contrary, it is entirely possible that Mycroft may be the worst "psychopath" psychiatry has ever had the displeasure of meeting. 

Nearly all patients with DPD have one particularly trait in common: a "mask of sanity"; this thin, veneer of normality that covers the terrifying truth of their psychiatric condition. 

Dr Checkley wrote a very famous book titled the "mask of sanity" and describe how people with DPD are the masters of mimickry and disguise. Only the ones who fail, who have cracks in their mask ever get to see a psychiatrist. The thousands out there who are too intelligent to reveal such flaws are never even suspected of being insane. 

Mycroft could possible be one such DPD suffer. It is actually impossible to tell from the few minutes of clips we have from him. That famous scene in the cafe with John could either be a true moment of brotherly love or a cold calculated attempt to play John's heart strings like a harp. It would be actually be something we would expect to see from a DPD sufferer - the use of feigned emotions to further one's goals. 

Is Britain being run by a "psychopath" so dangerous that not even Broadmoor will be able to contain him? It does make for a different type of story to tell on Halloween. 

Other Parts in the Series:

1. Sherlock is to Autism as Eeyore is to Depression

Feedback is always appreciated! I love having discussions with others. 

Tags: character: mycroft holmes, meta: mycroft holmes

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