Diagnosis sociopath: DSM/Hare

DSM
The scientific push to explain how actions were determined externally is attributable to the large behaviorist movement that occurred in the United States during the mid-20th century. This focus on deviant behavior was criticized by some because all classes of criminals (e.g., thieves, sex offenders) were pushed into the same category (i.e., Sociopathic Personality Disorder). In effect, the focus shifted from the abnormal internal processes of the psychopath to include generic and overly inclusive deviant behaviors of many types of (offending) individuals. Another distinction for this diagnosis was the existence of antisocial and dyssocial sociopaths. The dyssocial sociopath was identified as a professional criminal who could be extremely loyal to his comrades (e.g., members of organized crime).

DSM-II
The dyssocial sociopath distinction was eliminated with the publication of the DSM-II (APA, 1968). Smith (1978) contended that the extreme loyalty to family and friends made this classification represent no other pathology except illegal behaviors. The personality characteristics of the psychopath were not conveyed in the dyssocial sociopath. The antisocial classification that remained still focused on the psychopath’s personality traits. For example, the DSM-II described this type of individual as callous, impulsive, selfish, and unable to learn from experience. However, some critics maintained that the DSM-II did not provide specific diagnostic criteria for the disorder (Hare, 1996).

DSM-III and DSM-III-R
The issue of explicit diagnostic criteria was solved with the publication of the DSM-III (1980) and the DSM-III-R (1987). Following both manuals, the diagnosis for psychopathy was called Antisocial Personality Disorder (ASPD); however, it no longer focused on personality traits. The criteria were changed by emphasizing behaviors. The DSM-III Task Force felt that the clinical inferences necessary to determine the personality characteristics of a psychopath lowered the reliability of the diagnosis. Therefore, a diagnostic shift to behavioral characteristics commonly associated with the disorder was considered more reliable for identification purposes than were the personality factors explaining why the behaviors occurred (Hare, 1996). However, the new criteria were so broad they included almost every known criminal offense (Stevens, 1993).

At least one member of the DSM-III Task Force was not convinced that this new diagnosis appropriately represented the psychopathy construct it was designed to identify and measure. Millon (1981) wrote of his dissatisfaction with the Task Force’s diagnosis of ASPD, alleging that “the write-up fails to deal with personality characteristics at all, but rather lists a series of antisocial behaviors that stem from such characteristics”(p. 182). In addition, he explained that too great an emphasis was placed on delinquent and criminal behaviors for the diagnosis. Millon also cited instances where some individuals with similar psychopathic personalities will express these characteristics in socially appropriate ways. In other words, he argued that the ASPD diagnosis was overly inclusive. Following Millon’s (1981) criticisms, not everyone who engages in criminal behavior experiences an absence of anxiety, guilt, or has shallow emotions. Furthermore, some psychopaths do not fit under the ASPD diagnosis, given the heavy emphasis on illicit conduct in adolescence and adulthood. Indeed, consistent with Millon’s observations, some researchers conclude that the newest nomenclature for psychopathy (i.e., ASPD) sacrifices validity for the sake of reliability (Hare, 1998). Hart and Hare (1997) contended that “there is little systematic experimental evidence to support the validity of the DSM criteria” (p. 25).

DSM-IV (1994)
The objections leveled against the DSM determination of ASPD resulted in slight changes in the DSM-IV diagnosis. According to the DSM-IV (APA, 1994), ASPD “has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder” (p. 645). Hare (1998) suggested that although this inclusion makes it easier for forensic psychologists or psychiatrists to discuss psychopathy in their evaluations or court testimony, greater confusion exists regarding the association between ASPD and psychopathy. Indeed, although the DSM-IV diagnosis retains the emphasis on antisocial behavior, many individuals diagnosed may not be psychopathic.

HARE’S PSYCHOPATHY CHECKLIST–REVISED
This particular objection prompted Hare (1980) to develop his Psychopathy Checklist (PCL), followed by a more revised version; namely, the PCL-R. Both the PCL and the PCL-R attempt to operationalize the concept of psychopathy based on the primary features of Cleckley’s (1941) original criteria. The PCL-R is a more quantifiable and semistructured interview with good reliability, validity, and norms).

Factor 1 represents interactional/emotional style and has been described as aggressive narcissism . Items that load on Factor 1 are more indicative of personality traits, including, among others, (1) glibness and superficial charm, (2) grandiose sense of self-worth, (4) pathological lying, (5) conning/manipulative, (6) lack of remorse, (7) shallow affect, (8) callous lack of empathy, and (16) failure to accept responsibility for one’s own actions.

Factor 2 items address behaviors or behavioral styles common to psychopaths, including, among others, (3) proneness to boredom, (9) parasitic lifestyle, (10) poor behavioral controls, (12) early behavioral problems, (13) lack of realistic long-term goals, (14) impulsivity, (15) irresponsibility, (18) juvenile delinquency, (19) revocation of conditional release. Whereas Factor 1 items remain relatively stable over time, Factor 2 items can diminish with age. Additionally, in Hare (1996), only Factor 2 items have any correlation with the DSM-IV’s ASPD diagnosis.

The modern psychiatric diagnosis: DSM

This was an interesting NY Times op-ed about the DSM, its origins, and questioning its continuing role in society, written by a former contributor to the DSM.

I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.

Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.

D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.

Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories.

The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.

Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.

There were a couple things I thought this this piece did a good job of illustrating.  First, that the history of the DSM wasn't Allah speaking directly to his prophet who then immortally inscribed these truths into the first issue of the DSM, but that it was largely just an attempt to assemble what most people thought about things out of the primordial ooze that was mainstream psychology as recently as a few decades ago.  Second, that despite these somewhat inauspicious origins, most people believe the word of the DSM like it is the bible, including decisionmakers like courts and legislatures.  Third, that there will never be a perfect DSM because of fundamental disagreements and the accompanying political machinations amongst the experts that write it.  So, in a word, the DSM is not the most reliable system in the world.

The conclusion:

Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.

DSM-5

This was a fascinating Wired article conveying some of the most common criticisms of the proposed DSM-5: "To critics, the greatest liability of the DSM-5 process is precisely this disconnect between its ambition on one hand and the current state of the science on the other. On the authority of doctors and psychologists' dirty little secret:

The authority of any doctor depends on their ability to name a patient’s suffering. For patients to accept a diagnosis, they must believe that doctors know—in the same way that physicists know about gravity or biologists about mitosis—that their disease exists and that they have it. But this kind of certainty has eluded psychiatry, and every fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can’t rigorously differentiate illness from everyday suffering. This is why, as one psychiatrist wrote after the APA voted homosexuality out of the DSM, “there is a terrible sense of shame among psychiatrists, always wanting to show that our diagnoses are as good as the scientific ones used in real medicine.”

The solution and the problem that the solution created:

Since 1980, when the DSM-III was published, psychiatrists have tried to solve this problem by using what is called descriptive diagnosis: a checklist approach, whereby illnesses are defined wholly by the symptoms patients present. The main virtue of descriptive psychiatry is that it doesn’t rely on unprovable notions about the nature and causes of mental illness, as the Freudian theories behind all those “neuroses” had done. Two doctors who observe a patient carefully and consult the DSM’s criteria lists usually won’t disagree on the diagnosis—something that was embarrassingly common before 1980. But descriptive psychiatry also has a major problem: Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have “major depression,” no matter your circumstances or your own perception of your troubles. “No one should be proud that we have a descriptive system,” Frances tells me. “The fact that we do only reveals our limitations.” Instead of curing the profession’s own malady, descriptive psychiatry has just covered it up.

What is at stake:

At stake in the fight between Frances and the APA is more than professional turf, more than careers and reputations, more than the $6.5 million in sales that the DSM averages each year. The book is the basis of psychiatrists’ authority to pronounce upon our mental health, to command health care dollars from insurance companies for treatment and from government agencies for research. It is as important to psychiatrists as the Constitution is to the US government or the Bible is to Christians. Outside the profession, too, the DSM rules, serving as the authoritative text for psychologists, social workers, and other mental health workers; it is invoked by lawyers in arguing over the culpability of criminal defendants and by parents seeking school services for their children. If, as Frances warns, the new volume is an “absolute disaster,” it could cause a seismic shift in the way mental health care is practiced in this country. It could cause the APA to lose its franchise on our psychic suffering, the naming rights to our pain.

The future:

Some mental health researchers are convinced that the DSM might soon be completely revolutionized or even rendered obsolete. In recent years, the National Institute of Mental Health has launched an effort to transform psychiatry into what its director, Thomas Insel, calls clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses. The institute says it’s “agnostic” on the subject of whether, or how, this process would create new definitions of illnesses, but it seems poised to abandon the reigning DSM approach. “Our resources are more likely to be invested in a program to transform diagnosis by 2020,” Insel says, “rather than modifying the current paradigm.”

DSM-5 = "lack of validity"

Says the Dr. Thomas R. Insel, director of the National Institute of Mental Health. From the NY Times:


While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.

“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

Insel describes the problem of all psychiatric diagnoses:

“Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”

It's interesting, a lot of people will come on here and baldly assert, "sociopaths don't do this" or "that's not what borderline personality disorder is." And that's fine. I understand the flaws and ambiguities in my own working definitions of psychiatric disorders. And I also understand that despite the fuzziness of the definitions, it's still useful to acknowledge that there seems to be commonalities between certain categories of people that deserve further explanation. But I do believe that people have used the DSM unquestioningly for far too long, taking it to the level of being DSM apologists rather than accepting new information with an open-mind, and I'm glad that there is now more pressure to provide actual science behind the various assertions.

For more on the DSM-5's explicit rejection in one instance of actual scientific proof of a separate psychiatric disorder, see this New Yorker article's discussion of melancholia:

[T]he inclusion of a biological measure [for melancholia] would be very hard to sell to the mood group." Coryell explained that the problem wasn’t the test’s reliability, which he thought was better than anything else in psychiatry. Rather, it was that the D.S.T. would be "the only biological test for any diagnosis being considered." A single disorder that met the scientific demands of the day, in other words, would only make the failure to meet them in the rest of the D.S.M. that much more glaring.
***
This notion—that the apparent mental condition is all that can matter—underlies not only the depression diagnosis but all of the D.S.M.’s categories. It may have been conceived as a stopgap, a way to bide time until the brain’s role in psychological suffering has been elucidated, but in the meantime, expert consensus about appearances has become the cornerstone of the profession, one that psychiatrists are reluctant to yank out, lest the entire edifice collapse.

"What can be asserted without evidence can be dismissed without evidence."

DSM-5 vs. PCL-R

A reader comments about the differences between the proposed DSM-5 and the PCL-R:

As far as sociopathy goes, the DSM-IV diagnosis was woefully inadequate. It provided no real insight into the disorder and lacked strong empirical evidence; that is why scholars such as Robert Hare and Theodore Millon have said that sociopathy and antisocial personality disorder are two independent constructs and why Hare went further to create the psychopathy checklist. While the psychopathic checklist is a much more accurate diagnostic tool, it also lacks empirical evidence. For one, it looks at personality as a binary construct. You either you have it or not and if not. It says psychopaths are both quantitatively and qualitatively different from non-psychopaths. But personality is not that clean cut. Everyone has psychopathic traits to a greater or lesser degree. It also doesn’t take into account the heterogeneity within psychopathy. According to Hare for and individual to receive a diagnosis in psychopathy they would have to score relatively high on factor 1 and 2, but that is far from true. Some patients would score high on the disinhibited component others on the antagonistic component and while some score high on both. There is abundant evidence that the impulsive-antisocial (disinhibited-externalizing) and affective-interpersonal (boldness-meanness) components of psychopathy differ in terms of their neurobiological correlates and etiologic determinants according to the work group of the DSM 5. So as far as the DSM and sociopathy researchers go, yes, there has been a disagreement between the two and up until now I think the PCL-R was the most useful when comparing it to antisocial personality disorder, but in all honesty, the DSM 5 seems to have a stronger scientific and empirical basis to not only psychopathy but personality as a whole. 

The DSM 5 seems to have a stronger scientific and empirical basis to not only psychopathy but personality as a whole. In contrast to the PCL-R, the DSM 5 derived its criteria from scientific data not theory. In a contested article by Skeem and Cooke, "Is Criminal Behavior a Central Component of Psychopathy? Conceptual Directions for Resolving the Debate," the two colleagues posit that the field of forensic psychology has prematurely embraced Hare's Psychopathy Checklist-Revised (PCL-R) as the gold standard for psychopathy, due in large part to legal demands for a tool to predict violence. Yet the PCL-R's ability to predict violent recidivism owes in large part to its conflation of the supposed personality construct of psychopathy with past criminal behavior, they argue: 

“[T]he modern justice context has created a strong demand for identifying bad, dangerous people…. [The] link between the PCL and violence has supported a myth that emotionally detached psychopaths callously use violence to achieve control over and exploit others. As far as the PCL is concerned, this notion rests on virtually no empirical support…. [T]he process of understanding psychopathy must be separated from the enterprise of predicting violence.” 

Criminal behavior weighs heavily in the PCL's 20 items because the instrument emerged from research with prisoners. But using the PCL-R's consequent ability to predict violence to assert the theoretical validity of its underlying personality construct is a tautological, or circular, argument, claim Skeem and Cooke. Or, as John Ellard put it more directly back in 1998: 

"Why has this man done these terrible things? Because he is a psychopath. And how do you know that he is a psychopath? Because he has done these terrible things." 

All in all, the PCL- R tends to do a better job measuring criminality. Not psychopathy, which is a personality disorder and can’t be adequately recognized by a set of twenty criteria combined with an arbitrary diagnostic threshold. (That threshold being 30). 

Quintessential sociopath traits

I've been thinking recently about the diagnostic criterion for sociopathy/psychopathy/ASPD (to the extent that they overlap and/or are largely conflated with each other).

The dominant diagnostic tools are Cleckley's checklist, Hare's PCL-R, and the DSM-IVs criterion for ASPD. None of these diagnostic tools require all traits to be manifested in a patient in order to be labeled a sociopath. All of the diagnostic tools are based on the observable traits of those who have been diagnosed as sociopaths, which, apart from being rather circular, introduces the risk of biases that might skew which traits get included or not included -- biases of the researchers, of a particular context (e.g. prison), of cultural differences, or of possible comorbidity with other disorders. And of course, not every sociopath will look the same because even if they had the same "sociopath genes" (if such exist), those genes would still manifest themselves differently based on environment, intelligence, gender, age, education, other factors of their upbringing, etc.

With all of that said, I'm curious what people people think are the quintessential sociopathic traits. I thought we could pool our collective opinions, as a straw poll. With that in mind, I'm going to include Cleckley's checklist, Hare's PCL-R, and the DSM-IV list of traits. Could everyone who wants to participate choose 5 traits that you think are the most common, predominant, or defining traits of a sociopath? If you think that a trait is necessary to a diagnosis, could you put an asterisk by that particular trait? Finally, if you believe that there is an essential trait that is not included in any of the diagnostic criterion listed below, feel free to include them, indicated with a hashtag (#). I wonder if we'll do a better job coming to a consensus than others have.

Cleckley:
1. Considerable superficial charm and average or above average intelligence.
2. Absence of delusions and other signs of irrational thinking.
3. Absence of anxiety or other “neurotic” symptoms. Considerable poise, calmness and verbal facility.
4. Unreliability, disregard for obligations no sense of responsibility, in matters of little and great import.
5. Untruthfulness and insincerity.
6. Antisocial behavior which is inadequately motivated and poorly planned, seeming to stem from an inexplicable impulsiveness.
7. Inadequately motivated antisocial behavior.
8. Poor judgment and failure to learn from experience.
9. Pathological egocentricity. Total self-centeredness and an incapacity for real love and attachment.
10. General poverty of deep and lasting emotions.
11. Lack of any true insight; inability to see oneself as others do.
12. Ingratitude for any special considerations, kindness and trust.
13. Fantastic and objectionable behavior, after drinking and sometimes even when not drinking. Vulgarity, rudeness, quick mood shifts, pranks for facile entertainment.
14. No history of genuine suicide attempts.
15. An impersonal, trivial, and poorly integrated sex life.
16. Failure to have a life plan and to live in any ordered way, unless it be for destructive purposes or a sham.

Hare:
· glib and superficial charm
· grandiose estimation of self
· need for stimulation
· pathological lying
· conning and manipulative
· lack of remorse or guilt
· shallow affect
· callousness and lack of empathy
· parasitic lifestyle
· poor behavioral control
· sexual promiscuity
· early behavior problems
· lack of realistic long-term goals
· impulsivity
· irresponsibility
· juvenile delinquency
· failure to accept responsibility for own actions
· revocation of conditional release
· many short-term marital relationships
· criminal versatility

DSM-IV
- failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
- deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
- impulsiveness or failure to plan ahead;
- irritability and aggressiveness, as indicated by repeated physical fights or assaults;
- reckless disregard for safety of self or others;
- consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
- lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;

Ch-ch -changes

A reader informs me that aspies aren't the only ones getting reshuffled in the proposed new DSM.

Interestingly, the new DSM, or at least the draft presented online, (1) renames ASPD to "Antisocial/Psychopathic PD" and (2) completely removes NPD. Narcissists now have "a core personality impairment with prominent traits such as callousness, manipulativeness, histrionism and narcissism." Sociopaths on the other hand have "callousness, aggression, manipulativeness, hostility, deceitfulness, narcissism, irresponsibility, recklessness and impulsivity." It seems that under the new definitions sociopaths are just malicious, foolhardy narcissists with a diminished emotional repertoire. This is really a new perspective and one that might or might not be as absurd as it seems at first glance.

Again, this shows how the definitions (such as DSM) are completely misleading as to the depth of experience and as to the diversity of different wirings out there.

An Introduction to Psychopathy

I am still surprised by the amount of disagreement about psychopathy, sociopathy, antisocial personality disorder, etc. that you'll get from any source -- academic, pop psychology, etc. With that small caveat (nothing is definitive), I found this article on psychopathy to be a good overview with academic cites (and links in the original). Here are some selections:

While it is past antisocial behavior that is particularly important in predicting future criminal activity (Walters, 2003), it is CU (callous unemotional) traits that are at the core of developmental trajectory associated with psychopathy (Frick and White, 2008). The disorder is developmental. It has been shown that CU traits in particular and the psychopathy more generally are relatively stable from childhood into adulthood (Lynam et al., 2007; Munoz and Frick, 2007). In addition, the functional impairments seen in adults with psychopathy (e.g., in responding to emotional expressions, aversive conditioning, passive avoidance learning, reversal learning, extinction) are also seen in adolescents with psychopathic tendencies (see later).
***
Psychopathy is not equivalent to the psychiatric conditions of conduct disorder (CD) or antisocial personality disorder (ASPD) as defined by DSM-5 or their ICD-10 counterparts. The diagnostic criteria for these disorders focus on antisocial behaviors rather than on etiological factors such as the emotion dysfunction seen in psychopathy (Blair et al., 2005). As such these psychiatric conditions describe individuals with difficulties in executive dysfunction (Moffitt, 1993), as well as individuals with symptoms stemming from CU traits. Consequently, individuals with psychopathy are a more homogenous group than those individuals meeting the criteria for CD and ASPD (Karnik et al., 2006). It should be noted, however, that DSM-5 includes the specifier for CD ‘with limited pro-social emotions,’ which stem directly from research on youth with CD and CU traits (Pardini et al., 2010; Pardini and Fite, 2010). Furthermore, the diagnosis of ASPD now includes components of psychopathy (APA, 2013). While the disorder of psychopathy will still not be equivalent to the DSM-5 diagnoses of CD and ASPD, there will be greater overlap in diagnostic conceptualization.

Psychopathy is characterized by an increased risk for antisocial behavior (Frick and Dickens, 2006; Hare, 2003). While several psychiatric disorders and neurological conditions, including CD and ASPD (APA, 2013), confer an increased risk of reactive aggression (Anderson et al., 1999; Leibenluft et al., 2003), psychopathy is unique in that it conveys increased risk for instrumental aggression (Frick et al., 2003). 

Interestingly, an article that was cited included this assessment of treatment options: "While treatment recommendations are currently sparse, recent work has shown that previous assessments of treatment amenability in this population may have been overly pessimistic."

Also, because I had to look this up too:
"A classic measure of stimulus-reinforcement learning is aversive conditioning -- the individual learns that a particular stimulus is associated with threat. Individuals with elevated CU traits show marked impairment in stimulus-reinforcement learning. Indeed, an individual's ability to perform aversive conditioning at 15 years has predictive power regarding whether that individual will display anti-social behavior 14 years later (Raine et a., 1996)."

New article re Schema Therapy, etc.

 I stumbled upon this article from the American Psychological Association "A broader view of psychopathy" while looking for a quick legitimate source for psychopathy being a personality disorder and it had a wealth of interesting information including the origin of psychopathy being part of ASPD:

For these and other reasons, the mental health community has not had an easy time homing in on a uniform definition of psychopathy. For decades, its symptoms were examined in two very different populations: people in criminal or forensic settings and people in inpatient or community mental health settings. These groups had somewhat different characteristics, which led to different ways of conceptualizing and assessing psychopathy, said Florida State University psychologist Chris Patrick, PhD, who studies and has written extensively on the condition.

To add to the complexity, psychopathy is not a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V)—one reason the area tends to be both underfunded and undertreated, Marsh added. In part, that is due to earlier disagreements in the field: Some of those studying the disorder worried that a psychopathy diagnosis would stigmatize people too much, while others were concerned that clinicians would have difficulty in accurately assessing traits like callousness or cruel or indifferent disregard of others. So, although psychopathy was included in the first two editions of the DSM, it was replaced in the third edition by antisocial personality disorder (ASPD), which focuses mainly on the behavioral aspects of psychopathy, such as aggression, impulsivity, and violations of others’ rights, but only minimally on personality characteristics like callousness, remorselessness, and narcissism. As a result, only about a third of those diagnosed with ASPD also meet the criteria for psychopathy, according to research using validated scales, which often leads to confusion over how and if the two conditions are related, Marsh noted.

And regarding successful treatment, including schema therapy:

Collectively, these findings suggest that those with or at risk for psychopathy need more than single-dose therapy. Rather, therapy needs to be both correctly tailored to the problems the person is facing and of sufficiently long duration to ensure that changes stick, Viding said. 

More on IQ tests, intelligence, and sociopaths

From a reader:

The question of whether or not IQ tests are equally valid for sociopaths is an interesting one. Essay tests typically measure not only subject material mastery, but also how closely the opinions expressed by a test taker match those of the test grader. Poorly written multiple-choice questions may follow simple patterns e.g. longest answer is always right. If someone administering a test knows the answers and gives non-verbal cues, then they may just be measuring a Clever Hans effect. And of course having a copy of the answer sheet before the test can reduce performance to an act of memorization.

Any of these systematic difficulties would drastically decrease the g-loading of a test. After going through all the ways that test questions can potentially be `gamed`, we must face the truism that a g-loaded question is g-loaded question. A given question may be solvable by more than one means, but if the ability to solve it by any and all of these means has a strong enough correlation with the ability to solve a diverse enough body of other seemingly unrelated problems involving complexity, then the ability to solve it is a mathematically valid demonstration of general intelligence per Spearman's factor analysis.

I've never heard a good argument against this, so I'm not interested in debating it.

On the other hand, I may be interested in debating subtler points about interplay of the general factor and specific factors amongst different groups of people with certain sets of DSM-IV diagnoses. For example it's generally accepted that high functioning autistics are better than the general population at performing some cognitive tasks, and worse than the general population at performing others. A significant proportion of autistics exhibit such large discrepancies on Raven's Advanced Progressive Matrixes vs. Wechsler tests that the discrepancies in scores actually far exceed what can be accounted for by the sum of these test's specific factors as normed on the general population. This is true even when comparing the Raven's scores against some of the Wechsler subtests considered to have the best g-loading.

Autism is not as well understood as some other DSM-IV diagnoses, but the effect involving IQ score discrepancies appears analogous to the way that ADHD can be accurately diagnosed from disparities between Wechsler series sub-test scores. There are non-IQ related cognitive skills tests which can effectively screen for sociopathy to the extent that test subjects are not aware of how the tests work. Additionally, there's some anecdotal evidence that sociopaths may generally fare better in chronometric IQ testing than in other forms of IQ testing.

There are some parallels between thought processes of autistics, sociopaths, and people with 3+ sigma general intelligence (1 or less out of every 1,000 for the general population, or IQ of 145+ with a standard deviation of 15). This mostly relates to being more rational/calculating as opposed to emotional/reactive. There are ways in which all three groups seem to act stupidly, but most of these don't really relate to lack of general intelligence. Some relate to different emotional needs, or emotion processing deficits in said neuroatypicals, and at least a few actually result from cognitive deficits in the aggregate population.

I know someone who's convinced that sociopathy occurs with a greater frequency among the highly intelligent. Personally I don't think true sociopathy occurs with much greater frequency, but I do think that similarities in dick-head behavior result from similar secondary causes. For example, I've noticed that extremely intelligent people:

* don't feel compelled to follow social norms for the sake of following social norms
* don't hold authority figures in high regard
* don't make decisions based on emotions, including empathy
* can be very adept at using self-manipulation while justifying unreasonable behavior
* tend to experience disdain to a heightened degree when they do experience it

Sociopaths, Psychopaths, and Narcissists, oh my!

Here's a comment from a reader about the value of professional psychological diagnoses:

As you have diagnosed yourself as such I am not too worried however much your attempts at diagnoses you should have already figured out diagnoses are there for the pathetic people who cant understand what these things are. So they make up these diagnoses and things that should be corrected but if you think about it there is a DSM but no manual for whats normal no manual to counter it. Normalcy is what is socially acceptable and what is "Right" to these people. However there is no real right and no real wrong the only right there is is what us as an individual decide is best for ourselves. There maybe sociopaths in psychology but in reality its just another type of person their is no real disorder its a way of being.

I agree. Some people comment on this blog saying things like "sociopaths would never do/say x," which i figure are probably just arguments over semantics. For instance, one writer described the confusion over the terms sociopath and psychopath thusly:

Without getting into the politics surrounding the different diagnostic systems, people who were unaware of the need for precision and accuracy for research and assessment adopted a preference for using either ‘psychopath’ or ‘sociopath’ and came up with their own workable definitions. In other words, things got a little sloppy. I’ve even seen professionals use the term 'sociopath' but rely on the criteria specific to the concept of a psychopath. However, for researchers in psychopathy, ‘sociopath’ has a different connotation.

Which brings me back to the original question: the difference between a psychopath and sociopath. If you subscribe to the Hare criteria for a psychopath, then you see the conning, manipulative narcissistic liar and user as a psychopath, as long as he or she is completely lacking in remorse or empathy. The sociopath, however, is capable of guilt, caring, building relationships, etc., but only within a certain context. He or she will have loyalties to a specific group but not to society at large. They care nothing for social norms and will break them with impunity if it serves their purpose. So, on the surface, they may resemble psychopaths. However, they might genuinely feel remorse over harming someone within their group or family. They will have a moral code specific to that context: they might not lie, exploit, or manipulate within the group. Thus, they exhibit psychopathic behaviors in certain contexts but not all.

If these distinctions are accurate then maybe I am more sociopath, not psychopath. Or maybe we follow the DSM and say i have APD. Or maybe I'm a malignant narcissist? The labels are fuzzy, and ultimately they don't matter. I am who I am. I think what I think, feel what I feel, do what I do. I know I'm not typical. I don't care to debate the nuances of particular definitions or diagnoses, I just want people to know that they live in a world with people like me.

Cluster B

A reader gives a theory on the interactions between the DSM-IV's cluster B disorders:


My take on BPD is that it is a fake label, made up by "reformed" BPD's in the field. It's the lowest on the totem pole for the cluster B's, which succeed as follows; BPD, HPD, and AsPD...As for NPD, it does not belong here (although the new DSM is removing this and referring to Cluster B as the "Dramatic Cluster", which in a way it is. But in my opinion, it greatly differs from any type of sociopathy (AsPD). If you think about it, narcissists aim to make you dependent on them through deception and manipulation, while sociopaths seek outright control over someone. Also, Narcissists can empathize but only for themselves, while sociopaths have no ability to empathize at all. They pretty much just follow instinct and thus are “selfish” in their pursuits....A “survival of the fittest” mechanism.

But I feel that with the exception of codeps, all narcissists are horrid people, whereas all sociopaths are not.

Now here is the twist in my theory; AsPD can be comorbid with narcissism…and these are the most despicable/evil humans to walk the Earth (think Hitler…better yet, the embodiment of The Devil himself). Their aim is to have absolute control by any means without regard to any boundaries...societal or personal. But thisnarcissistic comorbidity  can run hand-in-hand with any of the remaining cluster B’s. I.e. Add Narcissism to BPD and that would give you Histrionic.

I am implying is that there are degrees of sociopathy, which can be exhibited in virtually anyone and narcissism is not a high form of it but separate…and when comingled, narcissism multiples the nastiness of sociopaths by a significant degree. BPD's have little narcissism, HPD's much more. AsPD's are higher on the sociopathic spectrum but this does not mean they have a degree of narcissism...add Narcissism to 
AsPD and you have Hitler/ Satan.

Psychopathy in the Army

From a reader:

As a veteran reading “Natural Killers – Turning the Tide of Battle” by Major David Pierson, I was a stricken by the assumption that it’s sociopaths who make up “natural killers” on the battlefield.  A member of Joint Special Operations Command, I was one of the guys sneaking around at night snatching up all those high value targets in the war on terror.  I was also a sniper in one of these units.  More than one source of data suggests psychopaths are drawn to commando units and sniper teams in particular.  Hell, I remember feeling a vague sense of discomfort after reading the last DSM criteria for ASPD, which listed impulsivity, aggression, tendency to break social norms, enjoy alcohol, and engage in a series of sexual relationships with little emotional attachment.  Most of us in my unit really enjoyed our time overseas, had fun in combat, and still crave the thrill of assaulting an objective.  The implications are… unnerving.  

But despite Pierson’s presumption, there’s a more nuanced perspective of ASPD, psychopathy, and sociopathy in relation to his idea of natural killers on the battlefield.  I believe archetypal psychopaths, though drawn to commando units, typically wash out of the elite selection processes.  This is because elite military units require a strong sense of social cohesiveness.  

Major David Pierson’s research draws heavily from Colonel Grossman’s research for his book On Killing, which drew heavily from the Gen. Marshall study on soldiers’ ability to kill following WWII.  Pierson describes an experience in Iraq, in which he witnessed a friend of his, a soldier, who had become battle fatigued after a brief fire fight.  He described the soldier as being “shaken by the episode,” and “not a natural killer.”  A natural killer wouldn’t have been shaken by the incident above.  A natural killer, Pierson goes on, is callous, adventurous, possesses a dark sense of humor, is athletic, and enjoys fighting.  

These are all the common traits of the unit I served with, and traits which couldn’t describe me better.  My unit rarely had problems with guys being battle-fatigued, and never had problems with guys failing to pull the trigger when needed.  Indeed, Pierson points out that aggressive psychopaths seek out positions in “airborne, Ranger, and special forces” units.  However, Pierson jumps to the conclusion that natural killers in combat are necessarily aggressive psychopaths.  After all, the traits described above do not necessarily a psychopath make.  In fact, they only apply to some facets of the diagnosis for ASPD in the DSM.  Though many expect most of us to be sociopathic, there’s actually limited data to suggest psychopaths are overrepresented in the profession. 

In my experience, commandos do have a certain profile that is almost ubiquitous in the industry.  Obviously, thrill seeking is the biggest prerequisite for special operations, but other, maybe surprising traits tend to pop up in the community.  We tend to be obsessive, single minded kind of guys, so the addiction trait is quite, quite common (every guy I know, including myself, are mild to severe addicts).  Next is some form of mild Attention Deficit Disorder.  Last, the guys are generally smart and eccentric.  These are not the “military” types you see running around with cropped haircuts and army boots in their off time (think – Marine) though they are tough guys.

That being said, some traits above do tend to mesh with some ASPD criteria.  Being an elite soldier means jumping out of planes and helicopters, mastering weapons of violence, applying medical trauma skills at the EMT-P level, and enjoying hand-to-hand combat.  There must be a powerful intuition to suppress emotions and engage in violence.  So to a certain extent, lack of empathy and remorse, a desire to break social norms, impulsivity, and aggression are prerequisites of the job.  While Pierson’s essay encourages leaders to identify natural killers in their units, the selection process for special operations units does a brilliant job finding them, institutionally.  

The selection process for elite units can be divided into two major assessment portions.  The hard physical selection weed-out process, like hell-week for navy seals’ Basic Underwater Demolition School, or the first week of the Ranger Assessment and Selection Program, coerces groups of cadets into performing strenuous group activities which depend on cooperation.  These drills require a sort of pack-like behavioral sense for cadets to succeed.  I can’t stress enough how socially demanding group drills are in a selection setting.
On the opposite end, however, comes individual talent drills which do not allow for others to pick up any slack.  One way the army selects for individual talent draws heavily from the British commando schools of the 40s, by requiring land navigation challenges, orienteering for the civilian reader, to assess whether an applicant can think on his feet and surmount arduous physical demands without any help from a comrade.  Land navigation, basically being dropped in the woods with a map and compass and told to find a bunch of points, is the LSAT or GMAT for the commando.  I suspect an intelligent psychopath could thrive on the latter, though struggle with the former.  

It’s hard to explain the mindset of working in an elite military unit.  While individual skills are necessary to succeed in the environment, group cohesion is equally important.  Small unit movements are a thing of awe.  Each member of the team works off one another, effortlessly, to flow through rooms, maintain 360 degrees of security, and achieve an objective.  There is an almost preternatural sense of being aware what the entire unit is doing, an exercise of reptilian and mammalian brain functions.  It takes a degree of yes, empathetic feeling to experience this as second nature.  The less you have to concentrate on what everyone else is doing, the more your cognitive attention can focus on what’s in front of you, and how to accomplish the larger mission.  This takes a lot of practice.  I would conjecture that the psychopath, who has a remarkably lower blood flow to the socially activated portions of the brain, would have a harder time concentrating during small unit tactics.  At least he’d have more difficulty developing the bonds necessary to thrive in the environment.  

All that being said, during my time as a DOD contractor and commando in Afghanistan and Iraq, I did come across what you’d call a traditional psychopath, albeit rarely.  I’m talking about the archetypal psychopath, the guy who stares at people and makes them uncomfortable, the guy incapable of reacting to other peoples’ emotional states without effort, who genuinely won’t feel guilty after a bad shooting incident, who sincerely enjoys playing head games with people.  But they had a hard time staying in a crew.  Sometimes it’d be the occasional inappropriate assault, sometimes the attempted murder of a comrade (yes, I’m not kidding).  There were a couple guys I knew, though, traditional sociopaths, but smart enough to fake it and control themselves to gel on a team.  I tended to enjoy their company, actually.  There’s a lot of entertainment to be had with a legit sociopath. 

Last, Pierson makes some great observations in identifying killers in a unit.  Overwhelmingly, guys in special operations come from middle-to-upper class backgrounds, are extroverted, and have higher technical scores than the rest of the military.  The class background in particular warrants further study.  While many who join the military do so for job skills or college money, men who enlist for commando units have no expectation of gaining either of these.  The types who volunteer for a professionally worthless job skill do so for adventure, and little else.  Ironically, volunteering for the most arduous, Hollywood positions in the military comes from a position of privilege.  I still struggle to wrap my head around that.  

Ultimately, I suspect most true aggressive psychopaths drawn to commando units wash out during some point of the selection process, or are kicked out because they either have a hard time getting along with comrades or get caught conducting illegal activity.  Otherwise Pierson’s description of a natural killer is pretty accurate.  To most of us who thrive during our time in a deadly unit, we have just enough ASPD traits to do well, but also enough empathy to flow as a cohesive unit and genuinely care for one another in the event of a casualty.  You could say we have ASPD in all the right places.  

Why we need psychopaths (part 2)

Regarding emotions and manipulation:


As psychopaths become less associated with demonic bloodlust a more accurate image is formed of just what this set of symptoms really looks like. They have “shallow emotions” which simply means their emotions are much less intense than non-psychopaths (DSM-IV-TR (2000) 4th ed., text. rev.). To demonstrate, imagine that a company is interviewing candidates to fill a vacant position. After several mediocre interviews, the recruiters are introduced to a charismatic, energetic, intelligent and striking woman whose credentials align perfectly with the job description. Obviously she is hired on the spot. Her low emotionality keeps her calm under pressure and cool-headed when resolving conflicts with co-workers. She’s able to make critical decisions for the company because “it’s not personal; it’s a business decision,” and has no problem sleeping at night while putting hundreds of employees out of work. Some of her co-workers go home emotionally exhausted after a day of rejected sales attempts, but not her. Little do they know her attractive outwardly appearance merely serves as a cover for the hollow shell within. Emotional detachment and regulation are important while in a business setting but for psychopaths their emotions are consistently “turned down.”

The flip side to this would be someone who is overemotional, which is often synonymous with “irrational.” This is why people are granted bereavement time from work. When mourning the loss of a loved one, they will be overcome by emotion and unable to concentrate effectively on their job duties. In some careers, such carelessness can be dangerous. It is this same extreme emotional state that sets the stage for crimes of passion because emotions have a tendency to distort reasoning - unbalanced emotions overwhelm balanced judgment (Hare 1999). For psychopaths, problems are evaluated in black and white terms with very little “gray area” distortion. Factor in the other leading characteristic, lack of empathy, and it is understandable why they describe having an “unburdened mind.” (Thomas 2013)

Psychopaths compensate for these deficits by learning to be experts on human behavior and honing their ability to mimic appropriate emotions. This overcompensation is often described as “deception” and “manipulation” in diagnostic criteria, but it is the same concept as “impression management” techniques regular people frequently utilize (DSM-IV-TR (2000) 4th ed., text. Rev). It is also called social masks in some literature. This is the idea that people slightly alter their personality depending on the situation they are in, thus “playing to the crowd” (Hare 1999). An example would be maintaining a professional appearance and demeanor while at work but “being yourself” at home. Adolescents or even young adults may use crude language in front of their friends but refrain in the presence of their families. Trying to show your best attributes during a first date and gradually “letting your guard down” describes the same concept. This could be “making a good impression” or being manipulative and deceptive depending upon perspective.

Regardless of one’s opinion of such practice, another important part of impression management and successful social interaction is learning to display proper emotion at certain times with appropriate intensity. Failing to display appropriate social cues can be off-putting and uncomfortable for the people who would describe this person as “hard to read.” So people learn to smile on cue, chuckle at a joke whether it is humorous or not, feign concern over a matter that doesn’t genuinely trouble anyone but the people involved, and so on. This process is generally automatic although errors occur occasionally, which is called “sending mixed signals.” It could be chalked up to having good manners and refined social skills but just how much feigned emotion people can handle is debatable. At what point is a person accused of “putting on a show” or being “fake?” When someone’s ego is at risk of injury they attempt to “save face” or avoid negative action. There is not a clearly defined manual for impression management and some pull it off better than others.

Take the Test

From TNP, describing the test:


It essentially breaks down all known psychopathic behavior into individual clusters that branch off of a base psychopathic tree. It's an evaluation, which a person can take themselves, to see just where they fall, and what characteristics and predominant in their personality. It takes away the arbitrary binary designation Yes/No to psychopathy, and instead focuses on the type of psychopathic features a person displays.

My academic sources are rooted in the works of Hare, Millon, and the DSM, though I do avoid complete redundancy, and nixed a few aspects that seemed obsolete, or unrelated to psychopathy.



The test itself:


Psychopathic Trait Tendency Assessment (PTTA)

This evaluation measures an individual's potentially psychopathic personality traits. It measures four different clusters of acknowledged psychopathic traits, and has a scoring system to measure if an individual meets enough of the criteria to acknowledge how much their personality is affected by each cluster of psychopathy. The evaluation also makes the distinction between each cluster being a primary personality tendency or a secondary one if indeed an individual displays enough traits for a cluster on a consistent basis.

This test does not evaluate whether an individual is a psychopath or not. It simply measure how their personality measures up to researched psychopathic features. The criteria, thresholds, and clusters are derived from the works and research of Hare, Millon, and the DSM IV.


Scoring System

Each trait has a max score of 4. There is no "3" in the scoring system, due to the severity of difference of a pathological trait, and a learned and utilized trait due to environmental adaptation necessities.*

0 - manifests rarely if at all
1 - manifests occasionally
2 - manifests frequently
4 - is an ever-present pathological manifestation in the personality of the person and is rarely if ever not utilized
  
*Examples of this would be when a person lives in a life-situation where classically psychopathic traits are needed to survive and thrive. This usually applies to hostile or high-stress work-environments for the likes of soldiers, career criminals, police, emergency responders, doctors/nurses, et cetera.


PTTA Evaluation

Assign a score to each trait based on the scoring system above. Add up the total for each cluster.

Core Base Psychopathic Personality Traits

-Superficial usage of charm
-Drastically lower levels of fear and anxiety
-Lack of empathy
-Lack of remorse
-Underdeveloped emotions
-Lack of respect or understanding of social norms and morals
-Impersonal relationships with family, friends and lovers
-Shallow to nonexistent affect
-High levels of cunning, deception and manipulation


Primary Psychopath threshold 28+/36
Secondary Psychopath threshold 20-27/36


Core Antisocial Personality Traits

-High levels of apathy and lack of life goals
-Disregard and violation of the boundaries of others
-Recidivist criminality
-Low levels of impulse control
-Low tolerance for frustration
-Prone to violent outbursts
-Prone to parasitic relationships with friends, family, and lovers
-Prone to indulgence of narcotics, alcohol, and other habit forming chemicals
-Sexual promiscuity

Primary Antisocial threshold: 28+/36
Secondary Antisocial threshold: 20-27/36


Core Narcissistic Personality Traits

-Highly susceptible to criticism or praise
-Grandiose self-image
-Sense of entitlement
-Delusional and unrealistic goals
-Obsession with self
-Requires constant attention and prefers to be the center of it
-Easily and often jealous and angry
-Wants and feels they deserve "the best" of whatever they want or need
-Indulges in fantasy of wealth, power and fame

Primary Narcissist threshold: 28+/36
Secondary Narcissist threshold: 20-27/36


Core Sadistic Personality Traits

-Prone to use physical or psychological harm to achieve their goals
-Humiliates or demeans others
-Utilizes unusually harsh punishments and lessons
-Takes pleasure or is amused by viewing or participating in the harming of animals and or humans
-Usage of intimidation
-Restricts the autonomy of those closest to the person
-Highly interested weapons, violence and torture
-Views others as toys to be played with and discarded when bored
-Takes pleasure in terrorizing and inducing fear and panic in others

Primary Sadist threshold: 28+/36
Secondary Sadist threshold: 20-27/36


Each core personality type represents a cluster of traits typically associated with Psychopaths and their behavior. As these are personality clusters, some are usually represented more than others, but it is possible that an individual would score very high on all clusters, or possibly only high on one if they were somewhere in the psychopathic spectrum.

Each cluster has nine traits, and the thresholds are kept at levels that require a majority of points being pooled into each cluster.

Secondary represents that an individual not only represents most traits to a moderate degree, but has at least one that falls into the realm of pathological.

Primary represents that not only does an individual have most traits to a moderate degree, but that they have most to a pathological degree.

Thresholds are not meant to include or exclude the possibility that someone encompasses a personality cluster. For example, an individual with only three or four traits in a cluster to a pathological degree would probably be represented by the personality cluster, even if the other traits did not appear present or that noticeable. It is rare (but not impossible) than an individual would only have a few traits in a cluster at pathological levels, and not the rest, to at least achieve the Secondary status for that cluster.

Sociopaths feel emotion

I have been surprised by how often I hear or read someone saying that sociopaths don't have emotions or can't form emotional bonds with other people. Most often it's people talking about how sociopaths are soulless monsters or must live lives completely devoid of any real meaningful relationships, but sometimes it's someone saying that he couldn't possibly be a sociopath because he feels emotions and love, etc. This is all fallacy. The three main diagnostic criterions actually have relatively little to say about emotions: Cleckley only mentions "general poverty in major affective reactions" and a poorly integrated sex life, Hare's PCL-R also lists shallow affect, and the DSM-V's ASPD only says that sociopaths tend to experience irritability and don't feel remorse. Nowhere does it say that sociopaths don't love. Nowhere does it say that sociopaths can't form emotional bonds. There is not a single historical example of a sociopath who is a completely emotionless, robot loner, so I don't know from where people are getting this image of the emotionless sociopath.

I thought about this popular misconception when I read this recent comment:

"How does a sociopath know when the missing emotions that make him supposedly so different, since he does not feel them, are feigned? In other words how does he learn to differentiate between feigned and real emotions?"

I am sociopathic, but have some emotion. These emotions are egocentric and only arise with events I am directly involved with, but they are still there. I feel joy and happiness at doing my favorite activities and I can (but may not always) feel anger or sadness when things do not go my way. Nonetheless, these are 'feelings' because they provide information that goes beyond the intellectual analysis of the situation at hand.

Because I have those feelings I can easily contrast those with situations where I do not or am faking them. If I am 'acting' in such a way to not betray myself, and my only contribution to that acting is my intellectual state, then I know that there is an absence of feeling there. If one tells me about how their friend died and they are in tears, I know that I must contribute with an appropriate response so that they 1) do not realize my status and 2) are not feeling any worse. Going through the motions because of this intellectual realization is far different than the automatic response given by most non-sociopaths. I think, by and large, we realize that we are not giving the same response as non-sociopaths because we realize that we have to craft the *entire* interaction with another person, not just the words.

But I don't think even this idea of faking emotions is so different than most people. Do you always mean it when you say "oh, I'm so sorry to hear that"?

Of course who knows whether sociopaths are feeling the same emotions that everyone else is, but I don't think anyone's emotional palette is completely identical to anyone else. Rather people's emotions are going to depend on their culture, their belief system, their education, the societal expectations placed on them, along with the vast natural and physical differences between people's brain and brain chemistry. This applies particularly to a complex emotion like love. I was actually just talking to a friend about how the only reason he can tell his wife loves him is that she very actively ensures that he is sexually satisfied (she's not a sociopath, but this "complaint" could very well be said about many sociopathic spouses). But whatever, right? Who is to say that this is a lesser or less desirable love than someone who would love to hold your hand in a hot air balloon?

Psychopath myths

From Scientific American, author of the book "50 Great Myths of Popular Psychology," Scott Lilienfeld, discusses some myths and misconceptions about psychopaths. Some of the highlights:

• Few disorders are as misunderstood as is psychopathic personality.
• Research also suggests that a sizable number of psychopaths may be walking among us in everyday life. Some investigators have even speculated that “successful psychopaths”—those who attain prominent positions in society—may be overrepresented in certain occupations, such as politics, business and entertainment. Yet the scientific evidence for this intriguing conjecture is preliminary.
• Psychopathy seems to be present in both Western and non-Western cultures, including those that have had minimal exposure to media portrayals of the condition.

Here are the myths:

1. All psychopaths are violent. Research by psychologists such as Randall T. Salekin, now at the University of Alabama, indicates that psychopathy is a risk factor for future physical and sexual violence. Moreover, at least some serial killers—for example, Ted Bundy, John Wayne Gacy and Dennis Rader, the infamous “BTK” (Bind, Torture, Kill) murderer—have manifested numerous psychopathic traits, including superficial charm and a profound absence of guilt and empathy. Nevertheless, most psychopaths are not violent, and most violent people are not psychopaths. . . . Regrettably, the current (fourth, revised) edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR), published in 2000, only reinforces the confusion between psychopathy and violence. It describes a condition termed antisocial personality disorder (ASPD), which is characterized by a longstanding history of criminal and often physically aggressive behavior, referring to it as synonymous with psychopathy. Yet research demonstrates that measures of psychopathy and ASPD overlap only moderately.
2. All psychopaths are psychotic. In contrast to people with psychotic disorders, such as schizophrenia, who often lose contact with reality, psychopaths are almost always rational.
3. Psychopathy is untreatable. . . . Although psychopaths are often unmotivated to seek treatment, research by psychologist Jennifer Skeem of the University of California, Irvine, and her colleagues suggests that psychopaths may benefit as much as nonpsychopaths from psychological treatment. Even if the core personality traits of psychopaths are exceedingly difficult to change, their criminal behaviors may prove more amenable to treatment.

Diagnosis sociopath: overview

This week I want to talk about the origin of and continuing confusion over sociopathy as a psychiatric diagnosis. Unless otherwise indicated, the material/information is taken (edited for length) from "The Confusion Over Psychopathy (I): Historical Considerations," a paper by Bruce A. Arrigo and Stacey Shipley, printed in International Journal of Offender Therapy and Comparative Criminology, 45(3), 2001 325-344.

Notwithstanding its extensive heritage, psychopathy has been plagued by changing and uncertain diagnostic nomenclature. For example, a great deal of confusion currently exists regarding the relationship between Antisocial Personality Disorder (ASPD), as identified by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM–IV), and the modern construct of psychopathy as explained by Cleckley (1941) and further refined and empirically validated by Hare (1985, 1991). Although contemporary research supporting the diagnosis of psychopathy is at its strongest, mental health professionals remain perplexed when diagnosing, treating, or making recommendations to the court system about these individuals.

In general, we note that the psychopathic label (i.e., explanation) has changed from the morally neutral view of Pinel (1801/1962) to the more truculent and disparaging characterization described by Kraepelin (1915). In addition, the designation itself has evolved from the unpopular term insanity, to the controversial expression moral, to the present moniker psychopathic. The elusiveness of the psychopathic construct and its meaning is further confounded by the theoretical basis out of which social scientists approach and investigate this mental disorder. Indeed, some researchers invoke descriptors for psychopathy, implying that the individual experiences morality problems that are solely personality based, exclusively congenitally or biologically derived (Ellard, 1988; Schneider, 1958; Smith, 1978), or principally behaviorally grounded (American Psychiatric Association, 1994). Moreover, notwithstanding these interpretations, Hare’s (1996) empirical and qualitative findings consistently demonstrate that the psychopath has distinctive affective, interpersonal, and behavioral attributes.

Psychopathic individuals historically and at present are almost uniformly considered difficult, if not impossible, to treat. We submit that the diagnostic confusion surrounding psychopathy (i.e., the label and its meaning) and the adverse consequences persons in the mental health and criminal justice systems (potentially) experience in the wake of such a determination, warrant closer scrutiny. Although clearly not exhaustive, this overview will provide an important backdrop, making it possible to assess provisionally how psychopathy evolved into a mental disorder and a pejorative label.

In particular, we will consider the logic of linking psychopathy, as applied to forensic clients, with the behavioral diagnosis of ASPD. This notwithstanding, the progression of thought contained within each of the components or categories demonstrates the course of psychopathy’s development and demonstrates how each has ostensibly functioned along a continuum (e.g., social condemnation as morally neutral to morally reprehensible, the disorder’s description based on personality to behavioral traits, and the locus of treatment from asylums to prisons).

An aspie's view of sociopathy

From an Aspie reader reader:

I found your blog by chance, a week or two ago, and can't help but feel intrigued. I have Asperger's syndrome (or as the next version of the DSM has it, "autism spectrum disorder") and the experiences you describe seem to have as many similarities to as differences from my own. 

We both find it necessary to mask ourselves for daily life because most people, most of the time, don't want to know what we're really like. They want an interface they know how to use, and an impression they can easily categorize. I don't switch masks with the fluidity of a sociopath, nor do I have as large a repertoire to choose from. I'd be willing to bet that I have to put more conscious effort into each one, so once a given mask passes I have greater incentive to stick with it and practice until perfect. (I don't know what you look like without yours, but at times when I can't maintain a mask I've been told that I either don't emote, or that the other (neurotypical) person doesn't know how to interpret my body language.)

Changing contexts, some facets of my personality behind that mask may fold away and others unfold such that people in either seem to form substantially different impressions of me, but I don't make a conscious decision to change what aspects I have on display, nor bother with deception. I simply omit what isn't relevant.

On the other hand, I'm pretty sure that I lack the typical sociopaths' need for stimulation and excitement, nor do any of your examples mention sociopaths with a typical autistics' sensory hypersensitivities. Sitting in a quiet room with dim lights, my experience is finally not *over*stimulating.

In that vein, there's one thing that I really don't understand. What do sociopaths get out of manipulating or otherwise having power over other people? What about it interests you? To my view, people are mostly boring and interacting with them is a nontrivial drain on my resources. (There are rare exceptions to that rule, and I've married one. He describes me as "asocial".) And so I have to ask: Why bother?

I look forward to your answer.

My response:

Thanks for this! I think that sociopaths get a lot of things from power. They get a sense of connection and intimacy with another person. They get a sense of purpose or sense that they are a being in the world that acts, not just gets acted upon. I think for a lot of sociopaths there was some sort of childhood trauma that made them feel like they weren't the masters of their own destiny. Not everyone is bothered by this, but I think for sociopaths it goes too strongly against their megalomania. But these are sort of just guesses. For me I have felt the need for power as a basic need, like the need for love or acceptance must be for most people, but I'm not sure why. Thoughts?

The psychopath problem

The psychology world seems to be taking a fresh look at sociopathy. Apparently once people dared question the infallibility of Hare's diagnostic criteria, the Psychopathy Check List Revised ("PCL-R"), it opened the door for other heresies against established views.

In his new book "Forensic Psychology: A Very Short Introduction," David Canter, a psychology professor at the University of Hudderfield, briefly describes the psychopath problem:

Until you have met someone whom you know has committed horrific violent crimes but can be charming and helpful, it is difficult to believe in the Hollywood stereotype of the psychopath. Without doubt, there are people who can seem pleasant and plausible in one situation but can quickly turn to viciousness. There are also people who just never connect with others and are constantly, from an early age, at war with those with whom they come into contact. If we need a label for these people, we can distinguish them as type 1 and type 2 psychopaths. The former have superficial charm, are pathological liars, being callous and manipulative. The clearest fictional example of this sort of psychopath is Tom Ripley, who has the central role in many of Patricia Highsmith’s amoral novels. The type 2 psychopaths are more obviously criminal, impulsive, and irresponsible with a history of juvenile delinquency and early behavioural problems.

Another label that may be assigned to people who are habitually involved in illegal, reckless, and remorseless activities that has a much broader net than ‘psychopathy’ is ‘antisocial personality disorder’. But we should not be seduced into thinking that these diagnoses are anything other than summary descriptions of the people in question. They do not help us to understand the causes of people behaving in these unacceptable ways. Some experts have even commented that they are actually moral judgements masquerading as medical explanations. So although the labels ‘personality disorder’ and ‘psychopath’ do summarize useful descriptions of some rather difficult, and often nasty, people, we need to look elsewhere for explanations of how they come to be like that.

The psychopath problem for society is "how do we keep psychopaths from acting in antisocial ways?" The psychopath problem for psychologists is "what are we really dealing with here?" Before psychologists can even begin understanding psychopaths, they must be able to identify them. Before psychologists can identify psychopaths, they must be able to understand them. It's a classic chicken/egg dilemma that leads critics like our favorite narcissist Sam Vaknin to quip that "psychopathy seems to be merely what the PCL-R measures!" and probably led the good folks putting together the DSM to eventually exclude psychopathy as a diagnosis in favor of the more criminal-sentencing friendly ASPD.

Still, these tests are being used, and brains of people flagged by these tests are being scanned and studied, helping scientists to learn more about . . . the brains of people who would be flagged by these tests. Some of the new discoveries or theories about psychopathy jive with my own personal experiences, and some of them strike me as being less than accurate -- an attempt to add an epicycle to support some of the weaker premises that provide the basis for the modern study of psychopathy. Maybe it is true that we are on the verge of a breakthrough, as some psychologists think -- a unifying theory of the causes and explanations for psychopathic behavior. If we are, I think it will have to be a product of fresh thinking, rather than continuing to focus on the same "20 items designed to rate symptoms which are common among psychopaths in forensic populations (such as prison inmates or child molesters)."