After the Germanwings Crash, 7 Lessons About Mental Illness
Clinicians can miss diagnoses, and patients can keep diagnoses private.
Posted Mar 30, 2015
Though we now know that Andreas Lubitz, the co-pilot who brought down the Germanwings flight, suffered from depression, we do not yet know what kind of depression, or if he had other issues such as a personality disorder.
We can only speculate, as a diagnosis can never be accurate without direct examination. A depressive illness that includes ebbing and flowing or masked psychotic features is a dangerous condition. Clinicians can miss this diagnosis because the psychosis is not always present at the time of the examination. Psychotic depression combined with lack of conscience, egocentricity, and grandiosity (personality disorder traits) is a recipe for disaster. Though it is not uncommon for people to have more than one condition, such a violent act is rare.
Certain forms of severe depression can spin off into short episodes of psychosis. For example: unipolar or bipolar (manic depressive) depression with psychotic features. The psychosis can contain aggressive components or not.
In bipolar (manic depressive) illness the manic episodes (which often occur less frequently than the depressive, and therefore the diagnosis might be missed) might involve grandiose fantasies as well as psychosis. Antidepressant medication can set off a manic episode in a person who has bipolar depression, so it is important to ascertain whether it is unipolar or bipolar disease.
An ex-girlfriend of the co-pilot claims he once told her, “One day I will do something that will change the whole system, and then all will know my name and remember it."
Perhaps he was revealing only the tip of the iceberg. This grandiose thought might have been far more monumental, relentless, or oppressive than he shared or than she realized. Some people suffer from intrusive, scary thoughts in an ongoing way. This can happen in obsessional disorders. (See below.)
Grandiosity, psychosis (hallucinations or delusions) and intrusive thoughts are a dangerous combination. Once, in residency, I did an intake on a young, impeccably dressed man who told me that after the session he was going uptown to murder his girlfriend. He couldn’t get the thought out of his mind and he appeared to be hallucinating. Needless to say, he had to be admitted.
Grandiose fantasies can be present in people with narcissistic or obsessional personality disorders as well. (There is also a “healthy grandiosity” that involves measured self-esteem, which is different.) These fantasies might offer pleasure and solace, or they might be excruciating.
Intrusive thoughts with destructive components can take over the mind of a conscientious person who cannot understand why they are having those thoughts, and it scares them. This happens in some obsessive-compulsive disorders.
If properly treated, people with mental illness can hold highly responsible positions, have wonderful relationships, and make excellent contributions. Untreated, one may still be mostly okay, but drastic moments still can arise. Because mania can be a high and because psychotic people do not know when they are psychotic, sometimes treatment is declined. People do have a right to refuse, unless they are dangerous to themselves or others. A colleague of mine was treating a psychotic woman on a ward who refused meds, threw a chair at an eight-months pregnant intern and killed the fetus.
How do we apply any of this to the co-pilot?
He was treated for a depression, plus he had vision problems, which might have eventually forced him to give up the career he worked so hard for and the heights he hoped to achieve. Despair and disappointment could have seeded chronic suicidal ideation. When the other pilot left the cockpit, an opportunity to both live out a grandiose fantasy and end personal suffering might have presented itself. The destructive wish may have gotten the better of his mind in the moment and, perhaps on a whim, he took the plane down. His greatest fear and his greatest wish may have been one and the same.
Illness may make one wish things or do things in the moment that their more stable self would not want.
Much is yet to be ascertained, but it does not appear that the pilot’s action was pre-meditated. If one has chronic suicidal thoughts and no fleshed-out plan, but the weapon is within reach, the destructive impulse can overpower the resistance. The fact that one could murder 149 people under any circumstance also begs the question of no conscience, or sociopathy (also known as psychopathy or anti-soclal personality), especially if one is intact enough to fly the plane at all.
People described the co-pilot as impeccably trained, affable, devoted, and nice. They just could not believe he was capable of such an act. And maybe in his healthier moments and mind, he wasn’t.
But just because someone is conscientious, intelligent, charming, and high functioning does not mean that their inner life is in harmony. Fears, paranoia, intrusive thoughts, and even delusions can haunt private moments. Trying to dismiss, mask, or will away biochemical phenomena may work for a time, but it is difficult to maintain. Perhaps he channeled intensities into running and flying, but then just couldn’t anymore. Maybe the vision problem was an intolerable defeat that broke him. It could be that at his core, he did not have enough compassion for others to stop himself.
The Andreas Lubitz case is conjecture at this point, but there are some general lessons to take away about the nature of mental illness:
- Competent, kind, lovely, high-functioning people can be mentally ill and others may have no idea of what goes on in their inner life.
- It is appropriate to keep a medical condition private unless it could endanger others.
- Personal responsibility and integrity play a part when it comes to a dangerous condition. Denial can be tempting.
- Intense immersion in activities can be a form of self-medication. This can help, but sometimes it is not enough.
- A combination of mental illness and personality disorder is not uncommon.
- People may only be in a psychotic state for a brief time and seem or be normal otherwise.
- Some cultures stigmatize psychiatric conditions more than others. Stoicism is an admirable quality but a poor choice in some situations.
We do not know exactly happened here, but thinking through the possibilities can help us be more aware and perhaps protect future lives.