On a more clinical level, guilt has many correlates with mental illnesses. Anxiety is associated with major depression in about seventy-five percent of cases, and guilt, being a form of anxiety, often is how anxiety presents. In these “biological” or endogenous cases, guilt is a secondary symptom of a primary mental illness. While there may be many guilt-like phenomena (negative thinking, self-deprecating comments), these generally improve when the depression is lifted. In these cases the treatment is not primarily to reduce guilt; rather, to lift the depression, often using medication, cognitive behavior therapy or a combination of both. When the depression resolves, guilt usually subsides.
Major depression is not the only mental illness associated with guilt. Guilt can co-exist with bipolar disorder, addictions, poor self esteem and primary anxiety disorders such as panic attack, phobia and obsessive-compulsive disorder. Guilt is often associated with difficult life decisions that may precipitate more minor forms of mental illness, like initiating a divorce or moving a family to accommodate a better job. These latter cases are referred to as Adjustment Disorders—normal though potentially life stressing events.
There also is the absence of guilt, which is not normally considered in ebooks on guilt. This condition is thought to be found in psychopaths, who in common parlance lack any true sense of guilt or remorse for harm they may have caused others. Instead, they rationalize their behavior, blame someone else, or outright deny their behavior or its consequences.
“I don’t feel guilt. Whatever I wish to do, I do.”–Jeanne Moreau
This is seen by psychologists as a failure to develop moral reasoning, an inability to evaluate situations in a moral framework, and an inability to develop empathy and to subsequently emotionally bond with other people. However, there is a rival theory of psychopathy in the developmental literature. My early training in this area suggested that antisocial personalities (the new name for psychopaths) actually are quite sensitive to other’s feelings; in fact, they may be so sensitive they cannot integrate their feelings into their also equally poorly formed ego-identity. This overload “causes” psychopaths to act selfishly in defense of their fragility, violating the rights of others in the service of self-preservation. This implies the sociopath also suffers from underlying narcissism. Regardless, on the surface, antisocial personalities are to be avoided because surely they will take advantage of someone. They will not appear to be impacted, i.e., to feel guilt.