Diagnostic Controversy
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Diagnostic Controversy: Psychopathy
See also: Psychopathy.
History
Interest in the psychopathic personality pattern goes back to Aristotle [1]. In 1801, Philippe Pinel described patients who were mentally unimpaired but nonetheless engaged in impulsive and self-defeating acts. He saw them as la folie raisonnante ("insane without delirium") meaning that they fully understood the irrationality of their behavior but continued with it anyway. Pinel was one of the last to study psychopathic personalities without including a moral judgment in his diagnosis. By the turn of the century Maudsley had begun writing about the moral imbecile, and was arguing that such individuals could not be rehabilitated by the correctional system.
Maudsley included the psychopath's immunity to the reformational effects of punishment, owing to their refusal anticipate further failure, and punishment. In 1904, Emil Kraepelin described four types of personalities similar to the antisocial personality disorder. By 1915 he had identified them as defective in either affect or volition, dividing the types further into categories only some of which correspond to the current descriptions of antisocial.[2]
In the 19th and early 20th century, the term was applied to conditions in which disturbances in emotion or actions occurred in the absence of any intellectual defect. These conditions were often referred to as manie sans delire, moral insanity, monomania, and folie lucide. [3] These types of cases sharply defined the fact that mental disorder could exist in a mind where reasoning was intact.
One condition that was identified during this early period of the development of modern psychiatry was called Impulsion (impulsive insanity). This was explained as a disturbance in actions that was "unreflective" (without due consideration for consequences) or "involuntary aggression" and the absence of any other symptoms of mental disturbance. According to Berrios [4], this provided the "kernel around which the notion of psychopathic personality was eventually to become organised." [5]
There was an important forensic reason for the development of the concept in this way: in order for legal testimony of clinicians to be relevant in criminal courts, there needed to be a classification that was something other, or beyond, the classification of "total insanity." It was clearly understood that there were criminals who were not functionally insane, yet who committed vile and heinous crimes because something was clearly "wrong" with them.
A change came in the first half of the 20th century: the concept of psychopathy was narrowed to refer to personality disorder in a general sense. Personality disorder was then defined as a "chronic disturbance of emotion or volition, or a disturbance of their integration with intellectual functions, that resulted in socially disruptive behavior." [6] This was an important shift from thinking of psychopaths as "damaged" individuals to understanding that they were "damaging." [7] However, at this point in time, there was little agreement among clinicians as to how to differentiate the various personality disorders or to name them. There was, nevertheless, a consensus that one important cluster of disorders was characterized by impulsive, aggressive and antisocial behavior.
According to Eastern European clinical psychologist, Andrzej Łobaczewski, the clinicians in Europe at the time maintained that there were several types of psychopathy including asthenic, schizoidal, anankastic, hysterical.[8] He also suggests that the practice of psychiatry and psychology are professions that are particularly attractive to psychopaths, an idea that is supported by Hervey Cleckley, Robert Hare and Paul Babiak, and that this is the primary reason for the historical diagnostic confusion and degradation of the study of psychopathy itself.
Łobaczewski discusses the fact that in Nazi Germany and Stalinist Russia, the psychological sciences were co-opted to support totalitarian regimes and that this was done by psychopaths in power who then set about destroying any possibility of accurate information about the condition being widely propagated. He points out that any regime that is composed primarily of pathological deviants cannot allow the science of psychology to develop and flourish freely because the result would be that the regime itself would be diagnosed as pathological thus revealing "the man behind the curtain." Awareness of the diagnosis would reinforce psychological resistance on the part of normal human beings who are the majority of any society, and would furnish them with new measures of self defense. He asks: "Can any pathological empire risk permitting such a possibility?" Any possibility of such a situation developing must thus be staved off prophylactically and skillfully, both within and without the empire.
Based on first hand observations of the phenomenon in question, Łobaczewski states that the repression of knowledge is undertaken in the typical manner of the psychopath: covertly and behind a "Mask of Sanity." In order to be able to control the psychological sciences, one must know or be able to sense what is going on and which fragments of psychopathology are most dangerous. A pathological political regime locates those individuals in the field who are psychopaths, (usually very mediocre scientists), facilitates their academic studies and degrees and the obtaining of key positions with supervisory capacity over scientific and cultural organizations. They are then in position to knock down more talented persons, governed both by self-interest and that typical jealousy which characterizes a psychopath's attitude toward normal people. They are the ones monitoring scientific papers for their “proper ideology” and attempting to ensure that a good specialist will be denied the scientific literature he needs. Łobaczewski writes about the problem as follows:
Scientific papers published under such governments or imported from abroad are monitored, research funds are denied to those who undertake research in certain directions. Specialists with superior talent can become the objects of blackmail and malicious, covert control. This of course causes the science of psychology to become inferior with reference to psychopathology. The entire operation must of course be managed in such a way as to avoid attracting the attention of public opinion. Often, scientists doing investigative work in this area are destroyed without a sound and suspicious persons are forced abroad to become the objects of organized harassment campaigns there. Written and unwritten lists are compiled for subjects that may not be taught, and corresponding directives are issued to appropriately distort related subjects. The list is so vast in the area of psychology that little remains of this science except a skeleton picked bare of anything that might be subtle or penetrating. A psychiatrist’s required curriculum contains neither the minimal knowledge from the areas of general, developmental, and clinical psychology, nor the basic skills in psychotherapy. Thanks to such a state of affairs, the most mediocre of physicians can become a psychiatrist after the barest minimum of course work. This opens the door of psychiatric careers to individuals who are by nature inclined to serving a pathological regime, and it has fateful repercussions upon the level of knowledge. It later permits psychiatry to be abused for purposes for which it should never be used.[...]
The essence of psychopathy may of course not be researched or elucidated. Appropriate darkness is cast upon this matter by means of an intentionally devised definition of psychopathy which includes various kinds of character disorders, together with those caused by completely different and known causes. One might admire how the above mentioned definition of psychopathy effectively blocks the ability to comprehend phenomena covered therein. ...
The “ideological” battle is thus waged on a territory completely unperceived by most people, including scientists and researchers in the field in question. In the meantime, however, the necessary scientific data and papers must be obtained somehow, taking difficulties and other people’s lack of understanding into account. Students and beginning specialists not yet aware of what was removed from the educational curricula attempt to gain access to the scientific data stolen from them. Science starts to be degraded at a worrisome rate once such awareness is missing. We need to understand the nature of the macrosocial phenomenon as well as that basic relationship and controversy between the pathological system and those areas of science which describe psychological and psychopathological phenomena. Otherwise, we cannot become fully conscious of the reasons for such actions. [...]
A normal person’s actions and reactions, his ideas and moral criteria, all too often strike abnormal individuals as abnormal. For if a [psychopath] considers himself normal, which is of course significantly easier if he possesses authority, then he would consider a normal person different and therefore abnormal... That explains why a [pathological] government shall always have the tendency to treat any dissidents as “mentally abnormal”. Operations such as driving a normal person into psychological illness and the use of psychiatric institutions for this purpose take place in many countries where [psychopaths achieve political power]. Contemporary legislation ... is not based upon an adequate understanding of the psychology of such behavior, and thus does not constitute a sufficient preventive measure against it. [...]
A normal person strikes a psychopath as a naive, smart-alecky believer in barely comprehensible theories; calling him “crazy” is not all that far away. Therefore, when we set up a sufficient number of examples of this kind or collect sufficient experience in this area, another more essential motivational level for such behavior becomes apparent. What happens as a rule is that the idea of driving someone into mental illness issues from minds with various aberrations and psychological defects.
...Well–thought out legislation should therefore require testing of individuals whose suggestions that someone else is psychologically abnormal are too insistent or too doubtfully founded. On the other hand, any system in which the abuse of psychiatry for allegedly political reasons has become a common phenomenon should be examined in the light of similar psychological criteria extrapolated onto the macro-social scale. Any person rebelling internally against a governmental system, which strikes him as foreign and immoral, and who is unable to hide this well enough, can easily be designated by the representatives of said government as “mentally abnormal”, someone who has a "personality disorder" and should submit to psychiatric treatment. A scientifically and morally degenerate psychiatrist becomes a tool easily used for this purpose. This becomes a method of terror and human torture... The abuse of psychiatry ... thus derives from the very nature of a government with psychopaths in power. After all, that very area of knowledge and treatment must first be degraded to prevent it from jeopardizing the system itself by pronouncing a diagnosis, and must then be used as an expedient tool in the hands of the authorities. ...
The psychopaths in power feel increasingly threatened whenever the medical and psychological sciences make significant progress. After all, not only can these sciences knock the weapon of psychological conquest right out of their hands; they can even strike at the very nature of such a government, and from inside the empire, at that. A specific perception of these matters therefore bids the psychopaths in power to be “ideationally alert” regarding psychology. This also explains why anyone who is both too knowledgeable in this area and too far outside the immediate reach of such authorities must be accused of anything that can be trumped up, including psychological abnormality. [9]
The Controversy
It is important when considering this question to understand that there is a controversy. On the one side, there is the traditional description of psychopathy derived from the above-mentioned European tradition discussed by Lobaczewski, which is closely related to the older North American Tradition of Hervey Cleckley, Robert Hare and others. This is in general agreement with the experiences of practicing psychiatrists, psychologists, criminal justice personnel, experimental psychopathologists, and even members of the lay public who have had personal encounters with psychopathy.
On the other side of the issue, is what is called a "neo-Kraepelinian" (Emil Kraepelin) movement in psychodiagnosis which is closely associated with research coming out of Washington University in St. Louis, Missouri. This latter view is most closely aligned with the diagnostic criteria of the DSM-III, DSM-III-R, and DSM-IV for Antisocial Personality Disorder. The fundamental approach of this school is that assessment of a psychopath rests almost entirely on publicly observable or known behaviors. The assumption is that a clinician is incapable of reliably assessing interpersonal or affective characteristics (the internal landscape). Another assumption is that early onset delinquency is a cardinal symptom of ASPD. This tends to put heavy emphasis on delinquent and antisocial behavior, i.e., publicly observable behaviors that may have no bearing on the internal make-up of the individual.
The criteria of the DSM-III for ASPD was decided by a committee of the American Psychiatric Association's DSM-III Task Force and was revised only slightly by another committee for the DSM-III-R. The DSM-IV criteria were also decided by committee, with little regard for empirical research. [10]. These criteria are less behaviorally focused and thus, somewhat resemble the criteria for other DSM-IV personality disorders.
According to Robert Hare et al, Cleckley, Łobaczewski, and many other experts in psychopathy, a diagnosis of psychopathy cannot be made on the basis of visible behavioral symptoms to the exclusion of interpersonal and affective symptoms because such a procedure essentially makes psychopaths of many people who are simply injured by life or society and allows the true psychopaths who have a well-constructed "mask of sanity" to escape detection.
Based on a growing body of literature, many (or most) psychopaths grow up in stable, well-to-do families, and become white collar criminals who, because of money and position, never have their private destructive behaviors exposed to public view and repeatedly avoid contact with the justice system. [11]
The widely publicized work of Robert Hare and Paul Babiak in their book Snakes in Suits demonstrates that psychopathy should be assessed using expert observer ratings based on a clinical interview, compared against a review of case history materials including any criminal or psychiatric records, interviews with family, friends, co-workers, employers and employees, supplemented with behavioral observations whenever possible.
The DSM-IV criteria do not constitute a scale or test.
The assessor determines if each criterion is present/true or absent/false. The final decision is: if the criteria are all present, then a lifetime diagnosis of ASPD is made; if one or more is absent, no such diagnosis is made. It can be observed that many psychopaths would easily evade detection via this system and many individuals who are possibly suffering from abuse or terrorization would be classified as ASPD.
Because of the problems with the DSM-III and DSM-III-R diagnosis of ASPD, the American Psychiatric Association carried out a muti-site trial to gather data in preparation for DSM-IV. [12] The field trial was designed to determine if personality traits could be included in the criteria for ASPD (which relies only on publicly evident behavior), without reducing reliability. The intention of those clinicians who lobbied for this was to bring ASPD back into line with clinical tradition and to end the confusion between ASPD and Psychopathy. The results of the field trials demonstrated that most of the personality traits that reflect the symptoms of psychopathy were as reliable as the behavior specific DSM-III-R items, thus invalidating the original premise for excluding personality from the diagnosis of ASPD/psychopathy. [13] In other words, including the PCL-R Factor 1 items in the criteria would have improved the validity of ASPD without sacrificing reliability. IRT analyses [14] show that Hare's PCL-R actually measures the latent trait of psychopathy across its entire range! Similar analyses of the field trial data show that the ASPD criteria was less discriminating of the psychopathy trait, particularly at high levels of the trait! In other words, the ASPD criteria set up by the DSM-III-R was designed - intentionally or not - to exclude the most psychopathic psychopaths!
Despite the fact that, after this study, there was an empirical basis for increasing the content-related criteria of ASPD in DSM-IV, this did not happen. It was argued by the DSM-IV committee that the average clinician would not use the carefully structured approach to the assessment of personality traits used in the field trial. Surprisingly, the criteria adopted for DSM-IV were not even evaluated in the field trial. What was evaluated was the 10-item set of adult symptoms (Criterion C) for ASPD listed in DSM-III-R. The seven-item set now listed in DSM-IV was derived from the 10-item set. More than that, the field trial did not include evaluations of Criterion B (conduct disorder before age 15), a criterion listed in DSM-IV as a necessary condition for a diagnosis of ASPD!
The DSM-IV text description of ASPD (which it says is "also known as psychopathy") contains references to traditional features of psychopathy but is incongruent with the formal diagnostic criteria in many ways. The "Associated Features" section of the text contains a statement parahrased by Robert Hare: "Lack of empathy, inflated and arrogant self-appraisal, and glib, superficial charm are features of ASPD that may be particularly useful in prison or forensic settings wherein criminal, delinquent and aggressive acts will be less specific to the disorder". [15] The problem that this presents is that the words used to describe these and related affective and interpersonal features are those typically associated with psychopathy and were based heavily on the 10-item psychopathic personality disorder set derived from the PCL-R. One is compelled to conclude that DSM-IV contains two sets of diagnostic criteria for ASPD, one consisting of antisocial and criminal behaviors, and the other consisting of these behaviors plus clinical inferences about personality. What is worse, the clinician is not given any guidelines on how to make these inferences.
One of the consequences of the ambiguity inherent in DSM-IV ASPD/ psychopathy criteria is that it leaves the door open for court cases wherein one clinician can say that the defendant meets the DSM-IV definition of ASPD, and another clinician can say he does not, and both can be right! The first clinician can use the formal diagnostic criteria exclusively while the second clinician can say "yes, the defendant may meet the formal criteria, but he or she does not have the personality traits described in the "Associated Features" section of the DSM-IV text". In other words, a good psychopath with a good lawyer can commit any crime and get away with it. This failure of the DSM-IV to differentiate between psychopathy and ASPD can (and undoubtedly will) have very serious consequences for society. Robert Hare writes:
... most jurisdictions consider psychopathy to be an aggravating rather than a mitigating factor in determining criminal responsibility. In some states an offender convicted of first-degree murder and diagnosed as a psychopath is likely to receive the death penalty on the grounds that psychopaths are cold-blooded, remorseless, untreatable and almost certain to reoffend. But many of the killers on death row were, and continue to be, mistakenly referred to as psychopaths on the basis of DSM-III, DSM-III-R or DSM-IV criteria for ASPD (Meloy). We don't know how many of these inhabitants of death row actually exhibit the personality structure of the psychopath, or how many merely meet the criteria for ASPD, a disorder that applies to the majority of criminals and that has only tenuous implications for treatability and the likelihood of violent reoffending. If a diagnosis of psychopathy has consequences for the death penalty - or for any other severe disposition, such as an indeterminate sentence or a civil commitment - clinicians making the diagnosis should make certain they do not confuse ASPD with psychopathy. [...] Diagnostic confusion about the two disorders has the potential for harming psychiatric patients and society as well. Camouflage Society In my book, Without Conscience, I argued that we live in a "camouflage society," a society in which some psychopathic traits - egocentricity, lack of concern for others, superficiality, style over substance, being "cool," manipulativeness, and so forth - increasingly are tolerated and even valued. ... it is easy to see how both psychopaths and those with ASPD could blend in readily with groups holding antisocial or criminal values. It is more difficult to envisage how those with ASPD could hide out among more prosocial segments of society. Yet psychopaths have little difficulty infiltrating the domains of business, politics, law enforcement, government, academia and other social structures (Babiak). It is the egocentric, cold-blooded and remorseless psychopaths who blend into all aspects of society and have such devastating impacts on people around them who send chills down the spines of law enforcement officers.
Psychopathy's relationship with other mental health disorders
Controversy
The issue of comorbidity is a topic of dispute between the above-mentioned schools of thought and the problems of the DSM-IV already discussed. It appears that the comorbidity of psychopathy with other psychiatric disorders is limited and confused. [16] Many of the traits that are commonly used to define psychopathy - impulsivity, egocentricity, callousness, irresponsibility, etc - also manifest in other disorders in varying combinations. In this respect, psychopathy is similar to the personality disorders defined in the DSM-IV. As mentioned above in the history section, according to Eastern European psychologist, Andrzej Łobaczewski, the clinicians of the old European school maintained that there were several types of psychopathy including asthenic, schizoidal, anankastic, hysterical.[17]
Psychopathy, as measured on the PCL-R, is negatively correlated with all DSM-IV Axis I disorders except substance-abuse disorders. PCL-R Factor 1 is correlated with narcissistic personality disorder and histrionic personality disorder. PCL-R Factor 1 is associated with extroversion and positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of nondeviant social functioning).
PCL-R Factor 2 is particularly strongly correlated to antisocial personality disorder and criminality. PCL-R Factor 2 is associated with reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence.
Diagnosing Psychopathy in Children
Psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing psychopathy and similar personality disorders in minors. Psychopathic tendencies can sometimes be recognized in childhood or early adolescence and, if recognised, are diagnosed as conduct disorder. It must be stressed that not all children diagnosed with conduct disorder grow up to be psychopaths, or even disordered at all, but these childhood signs are found in significantly higher proportions in psychopaths than in the general population.
Children showing strong psychopathic precursors often appear immune to punishment; nothing seems to modify their undesirable behavior. Consequently parents usually give up, and the behavior worsens.[18]
See: Psychopathy in Children
Implications for the Law and Society
It is important to note that psychopathy also has various, quite separate legal and judicial definitions that should not be confused with the medical definition. Various states and nations have at various times enacted laws specific to dealing with psychopathic offenders, and many of these laws are active, on statute, today:
- Washington State Legislature[19] defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field and manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible".
- In 1939, California enacted a psychopathic offender law [20] that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law [21] attempted to further clarify this to the point where anyone examined and found to be psychopathic was to be committed to a state hospital and anyone else was to be sentenced by the courts.
- "Psychopathic Disorder" is legally defined in the The Mental Health Act (uk) [22] as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned".
In the past few years, the legal system has changed dramatically in regard to diagnoses of psychopathy among criminals. Whereas before, a clinical diagnosis of psychopathy was of little value in predicting criminal behavior, after the adoption of Robert Hare's PCL-R, the association between psychopathy and crime acquired empirical validity. There is now extensive evidence that, despite their statistically small number in the general population, psychopaths make up a significant proportion of prison populations and are responsible for a shocking amount of crime and social distress across the board.
The features that define the psychopath - they are emotionally unconnected to the rest of humanity and they view others as little more than objects - make it quite easy for them to victimize the vulnerable and to use whatever means they choose to obtain what they want in the way of material goods and power.
Nevertheless, criminal behavior is far more common in society than psychopathy. Non-psychopaths routinely engage in less serious criminal conduct or isolated instances of serious criminal acts. But the criminal careers of psychopaths are qualitatively different. [23] The psychopaths criminal behavior is even different from non-psychopaths whose criminal conduct is extremely serious and persistent. More than this, the studies show that the antisocial behavior of psychopaths is motivated by different factors than those things that motivate non-psychopathic criminals. The psychopath's M.O., the types of victims they choose, their behavioral profile in committing crimes is also different.
Psychopaths begin their criminal careers at a very young age and continue to engage in such activity throughout their lives [24] though studies show a marked reduction in criminality around the age of 35-40 with respect to non-violent crimes. [25]. But, this does not mean that they have given up crime, it just means that their apparent criminal activity has decreased to the level of the average, non-psychopathic, persistent offender. It may also mean that they learn how not to get caught. The psychopathic tendency to violent crime and aggressive behavior does not appear to decrease with age. [26]
The question must be asked: are age-related reductions in the criminality of psychopaths a reflection of the fact that there are changes in their core personality traits?
The answer seems to be no. A PCL-R study of a large sample of male offenders ranging in age from 16 to 70 was conducted by Harpur & Hare in 1994. The scores on Factor 2 (socially deviant features) decreased sharply with age, while scores on Factor 1 (affective/interpersonal features) remained stable. This indicates that apparent age-related changes in the psychopath's antisocial behavior are not paralleled by changes in their egocentric, manipulative and callous traits, the fundament of psychopathy.
Psychopaths have a higher rate of violent crimes such as armed robbery, robbery, assault, and they engage in violence and homosexual aggression at a higher rate in prisons. Of psychopaths and non-psychopaths violent offenders in prison populations, psychopaths commit about three times more violent crimes.
Psychopaths not only have higher rates of violent crime, they commit different types of violent crimes than non-psychopaths. Two thirds of the victims of psychopaths were male strangers while two thirds of the victims of non-psychopaths were female family members or acquaintances. Non-psychopaths commit acts of violence while in states of extreme emotional arousal, while psychopaths cold-bloodedly select their victims for revenge or retribution. That is to say that psychopathic violence is instrumental, a means to an end, predatory. [27]
The fact that psychopathy is a risk factor for high rates of recidivism is well established.
Psychopaths and Sexual Violence
Among sex offenders in a treatment facility, rapists, those who had assaulted adolescents, and those who had assaulted children, had a base rate of psychopathy (PCL-R) of 76.5, 24.0, and 14.8 percent respectively. Half of all serial rapists may be psychopaths [28]
Rapists are classified into four basic types: vindictive, opportunistic, sadistic and non-sadistic. The primary motivation of the sadistic and non-sadistic types is sexual; the primary motivation of the vindictive and opportunistic types is aggressive or hostile. Psychopaths are found at a high statistical level among opportunistic and sadistic rapists. 81% of psychopathic rapists and 56% of non-psychopathic rapists were classified as either opportunistic or vindictive. [29]
Psychopaths use more frequent and more severe violence in the commission of sex offenses. The studies suggest that psychopathy may be associated with sexual sadism. High PCL-R scores are positively correlated with sexual arousal by violence assessed by penile plethysmography. [30]
Sex offenders are resistant to treatment [31], but it is the psychopaths among them that are most likely to re-offend early and often. [32]
One study found that within six years of release from prison, more than 80% of psychopathic sex offenders had violently recidivated, but only 20% of the non-psychopaths had done so. Many, but not all, of these offenses were sexual in nature. [33] In another follow-up study of a large sample, researchers obtained similar results with the additional report: sexual recidivism was strongly predicted by a combination of a high PCL-R score and phallometric evidence of deviant sexual arousal, defined as any phallometric test that indicated a preference for deviant stimuli such as children, rape cues, or nonsexual violence cues. [34]
Recent advances in neuroscience have brought about powerful new tools for determining if psychopathy is the result of structural or functional anomalies, or disruptions in the normal transmission of information in the brain. Magnetic Resonance Imaging is very promising in these studies. More research and more funding is needed.
But, just as we nave noted the resistance of those individuals who control the arbiter of our psychological reality - the DSM-IV - are reluctant to admit a coherent and accurate diagnostic criteria of psychopathy, so are those same groups reluctant to fund the research on psychopathy that is so desperately needed.
While few psychopaths commit violent crimes, the callousness of the average psychopath usually ranges through subtle, but still devastating misdeeds:
Parasitically bleeding other people of their possessions, savings, and dignity; aggressively doing and taking what they want; shamefully neglecting the physical and emotional welfare of their families; engaging in an unending series of casual, impersonal, and trivial sexual relationships; and so forth." [Hare, 45].