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If they are fortunate, they may have the support of a Friend to Psychos. If they're terribly unfortunate, the plot will conspire to make their already-difficult struggle even harder for them; it may even become necessary for them to give in to get out.
This is a very particular subtrope of the Tragic Flaw; examples that are about temptations and tendencies that are not actually insanity go there.
Truth in Television for many people with mental illnesses, by the way. However, despite the scary-sounding trope name, most Real Life people in this situation wouldn't be dangerous to anyone except maybe themselves if they lost control of their illness. Being Ax Crazy is a lot more common in fiction than reality, after all.
Anime and Manga
- Soul Eater has Dr. Franken Stein who, while pretty unnerving in his own right, spend much of the first season fighting the Madness inside him.
- The Riddler gets an issue of The Batman Adventures in which he attempts to circumvent his obsession with leaving clues to lead Batman to him by instead leaving clues that lead to other criminals. This works out fine until Batman pieces together hidden riddles in each of the clues that leads him to the Riddler anyway. When he realizes that he has done this, he is heartbroken.
Riddler: "You don't understand. .. I really didn't want to leave you any clues. I really planned never to go back to Arkham Asylum. But I left you a clue anyway. So I... I have to go back there. Because I might need help. I... I might actually be crazy."
- Batman himself, and other members of the Bat family, are sometimes implied to worry about their own mental health. In an issue of Robin, the titular boy wonder says he's afraid Batman might be going crazy. His girlfriend, also a masked vigilante, just laughs and says, "Well, look at us."
- In the Death Note AU Point of Succession Light is implied to be one. While talking with Beyond he seems to realize that there might be something fundamentally flawed with his own psychology:
Light: You knew this was a temporary arrangement. It's not like we could talk forever.
Beyond: I think we could. And never get bored. You aren't a boring individual Sweetie Jam, despite what you try so hard to show the world. And me, I know I'm not boring.
Light: Don't be too sure hun, the killing people thing gets old real fast.
Beyond: How would you know?
Light: We all have fantasies. Some are just bloodier than others.
- Light in Ragnarok a Death Note AU where his father caught onto Light's growing mental problems early enough to retrain him out of his Black and White Insanity to follow a different moral code. He constantly struggles with this, often catching himself thinking of the criminals he pursues as a detective as "Evil" and has to constantly remind himself "Shades of gray, Light. The world exists in shades of gray."
- John Nash is in this position in A Beautiful Mind, once he figures out that he actually is schizophrenic. By the end of the film he manages to keep himself productive without medication - which interferes with his mathematical genius - by constantly checking to make sure other people can see new people he meets.
- Grosse Pointe Blank:
Dr. Oatman: You didn't tell me what you did for a living for four sessions. Then you told me. And I said, "I don't want to work with you any more." And yet, you come back each week at the same time. That's a difficulty for me. On top of that, if you've committed a crime or you're thinking about committing a crime, I have to tell the authorities.
Martin: I know the law, okay? But I don't want to be withholding; I'm very serious about this process. [Beat] And I know where you live.
- John Wayne Cleaver is not a serial killer, but he is acutely aware of how likely he is to become one. He's not technically a sociopath, but only because until he turns 18 the relevant diagnosis is Conduct Disorder. He has a strict list of rules to adhere to to keep himself functional, barely managing to pass himself off as normal most of the time... and then events conspire to give him every good reason to start breaking his rules to protect himself and his family.
- Zane, in the Mistborn trilogy, is fully aware that he is insane (he understands that hearing the voice of "God" tell you to kill basically everyone you meet obviously isn't normal), but he feels that it isn't an excuse for irrational behaviour and that it is merely a flaw he must overcome. In the end, it turns out that while Zane is an unstable psychopath, the voice he was hearing in his head was quite real- it was the series' Big Bad, and while it wasn't quite God, it was pretty much the next step down. So even though he was crazy, he wasn't as crazy as he thought he was, if that makes sense.
- Patrick Bateman in American Psycho fantasises about killing people and often takes drugs to suppress his urges. However he gets worse, and finds himself killing people regularly just for the thrill of it. He mentions this to other people as a cry for help, but they don't even notice it. Because of this, it can be interpreted that nobody seems to mind (after all, he's part of a rich class who could buy themselves out of prison), that no one is actually listening to anything he says (it is a parody of the 80s yuppie culture) or that he's totally deluded and that he never killed anyone nor mentioned it to anyone.
- Dexter is an excellent example of the Reluctant Psycho who uses a productive or at least acceptable outlet to relieve his issues - through vigilante justice, in his case.
- Sherlock is typically perfectly willing to embrace his sociopathic tendencies, but occasionally shows hints of inner turmoil over whether they are actually more of a strength or a weakness. (John is helping him deal with the aspects that cause him problems; Mycroft is not nearly so conflicted.)
Sherlock: Look at them. They all care so much. Do you ever wonder if there's something wrong with us?
Mycroft: All lives end. All hearts are broken. Caring is not an advantage, Sherlock.
- In The Reichenbach Fall, he consciously becomes a full Reluctant Psycho after the police department's perception of him, heavy on the 'psycho' and light on the 'reluctant', goes wrong in the worst possible way.
- Firefly: River Tam early on appears to be simply insane, but as the series progresses it becomes clearer and clearer that she can understand what's happening and recognizes how very screwed up she's become. Whedon pulls no punches in showing just how much this hurts her.
- In the Criminal Minds episode "Friends Like These" the unsub was said to be suffering from paranoid schizophrenia and insomnia. Once his medications stopped working his hallucinations taunted him into murder since the only way he could sleep was after the adrenaline rush from the kills. Throughout the episode he was begging "his friends" to just go away because he didn't want to kill and just wanted to sleep.
- Lie to Me - there was an episode called "The Core Of It" where the main suspect/witness was a young woman suffering from Dissociative Personality Disorder. When they got around to talking to the original personality she was a wreak because she had no control over the other personalities - a law student and a prostitute. She is trying to fight it - just failing.
- Through the entire first season of Heroes this was the struggle for Nikki Sanders.
- A sort of odd example in Druitt from Sanctuary. He's an abnormal whose power is to teleport, but each time he teleports he becomes susceptible to an energy being who eventually takes up residence in him. This drives him to becoming Jack the Ripper, but once he's not a villain in the series he's struggling to make sure he doesn't go mad again and even takes medication to make sure. It's not a possession - the presence of the being just makes him mentally unbalanced in the form of bloodlust and rage, not actually forces him to do anything.
- Three Days Grace has the song Animal I Have Become, from the Reluctant Psycho's perspective.
- Similarly, Skillet's Monster.
- American McGee's Alice, especially in Madness Returns, when she's consciously aware that she's been in an insane asylum.
Djaya Sumatera: When you're a recovering mad scientist, you're always afraid you'll lose control and wake up some morning with a half-built time machine in the living room and a plan to go back in time to pants Hitler.
- Jack Delitt from Newheimburg has a major problem controlling his paranoia.
- Vriska Serket, to oversimplify grossly, cycles between 'I know exactly what I'm doing, and anyone who 8urns themselves on all the irons I've got in the fire totally deserved it 8ecause I'm JUST TH8 AWESOME!!!!!!!!' and 'I'm a horri8le person, what the hell is wrong with me, why doesn't everyone h8 me????????' which then tends to lead back into the former by way of 'You SHOULD h8 me! I'll MAKE SURE that you h8 me!'. She starts out in a fairly low-key phase two, but the phases intensify and she spends increasingly more time in the first category as the series progresses, since SGRUB is basically tailored to feeding her megalomania.
- The Nostalgia Critic. He regrets his psychotic episodes, doesn't want them to happen, and tries to tell people that he's down to earth and logical instead.
- Truth in Television. Charles Whitman, before barricading himself in a belltower and killing 14 people, wrote a suicide note explaining that he knew something was very, very wrong with him and to use any money left over from his life insurance to pay for research to prevent it from happening again.