Friday, April 23, 2010

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.

Thursday, April 22, 2010

Diagnosis sociopath: mask of sanity

(cont.)
The publication of Cleckley’s text, The Mask of Sanity (1941), marked the beginning of the modern clinical construct of psychopathy, and his characterization has remained relatively stable to the present day. Cleckley based his description of the psychopath on observations of White, middle-class male patients, residing as inpatients of a mental hospital. The conceptualization of the psychopath by Cleckley focused on the patient’s intrapersonal characteristics or “inferred, nonobservable, processes."

Cleckley recognized that many psychopaths never became involved with the criminal justice system. Moreover, many could succeed in business or in other endeavors, particularly in those careers that offered considerable material success. Cleckley observed that the primary psychopathic characteristics of glibness, superficial charm, emotional detachment, and lack of remorse or guilt could be used for successful criminal or noncriminal careers. Psychopaths can pursue what they want without experiencing anxiety attributable to a concern for how their actions might impact others.

In the wake of Cleckley’s findings, the word psychopath became popular among laypersons as well as mental health professionals. Ellard attributes this notoriety to the term’s status as both an explanation for and a cause of depraved and frequent criminal behavior. He cautions, however, that this logic was as inherently circular and suspect during Cleckley’s period as it is today. Illustrating the tautological nature of Cleckley’s psychopath, Ellard questions, “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”.

Wednesday, April 21, 2010

Diagnosis sociopath: the hate

(cont.)
The appropriate designation for what is today known as psychopathy underwent several changes and iterations. In 1891, Koch used the term psychopathic inferiority to characterize individuals who engaged in abnormal behaviors due to heredity but who were not insane. They were determined to have moral defects, but these defects were not equated with viciousness or wickedness. This new terminology (i.e., psychopathic inferiority) described emotional and moral aberration based on congenital factors and found wide acceptance in Europe and America. However, notwithstanding Koch’s efforts, the meaning of psychopathy in subsequent years once again became something quite pejorative but also something more reflective of the internal world and personality traits of the individual.

Maudsley (1897/1977) was a British psychiatrist who asserted that persons prone to moral imbecility could not be rehabilitated in prisons. Maudsley argued that moral imbecility was caused by cerebral deficits. As such, he believed it was useless to punish those who could not control their actions and wrote the following as evidence of moral imbecility: "When we find young children, long before they can possibly know what vice and crime means, addicted to extreme vice, or committing great crimes, with an instinctive facility, and as if from an inherent proneness to criminal actions . . . and when experience proves that punishment has no reformatory effect upon them—that they cannot reform—it is made evident that moral imbecility is a fact, and that punishment is not the fittest treatment of it."

Krafft-Ebing (1904) was even less sympathetic toward those considered morally depraved[,] assert[ing] that such individuals were “without prospect of success” and commented that “these savages . . . must be kept in asylums for their own[good] and [for] the safety of society.” It was at this historical juncture that psychopathic individuals were regarded as impervious to rehabilitation and that chronic social deviance was equated with pathology.

By 1915, Kraepelin expanded Koch’s psychopathic inferiority terminology to contain categories essentially defined by the most vicious and wicked of disordered offenders. His psychopathic personalities described in detail the “born criminal . . . the excitable, shiftless, impulsive types, the liars, swindlers, antisocial and troublemaking types”. Clearly with these characterizations, Kraepelin moved the focus of psychopathy back to one of moral judgment and social condemnation.

Interestingly, as Millon et al. (1998, p. 19) note, his categories of psychopathic personalities more closely represent our conceptualization of psychopathy and ASPD today. He described these disordered individuals as "the enemies of society . . . characterized by a blunting of the moral elements. They are often destructive and threatening . . . there is a lack of deep emotional reaction; and of sympathy and affection they have little. They are apt to have been troublesome in school, given to truancy and running away. Early thievery is common among them and they commit crimes of various kinds."

Tuesday, April 20, 2010

Diagnosis sociopath: origins

(cont.)
As previously stated, the psychopathy construct has a long history with changing personality patterns and clinical characteristics, dating back through the past two centuries.

Phillipe Pinel is generally credited with recognizing psychopathy as a specific mental disorder. Pinel advocated for appropriate, moral treatment rather than cruel interventions (e.g., bloodletting, cold baths) as the preferred method of intervention for the psychiatrically ill (Pinel, 1801/1962). Pinel’s contributions occurred in France shortly after the French Revolution. Prior to this time, France was ruled by a strict class structure and sanity was judged by the Old Testament of the Bible. In 1801, Pinel observed that some of his patients engaged in impulsive acts, had episodes of extreme violence, and caused self-harm. He noted that these individuals were able to comprehend the irrationality of what they were doing. There was no evidence of what is now considered psychosis, and their reasoning abilities did not appear to be impaired. He described these men as suffering from manie sans délire (insanity without delirium). As Pinel explained, “I was not a little surprised to find many maniacs who at no period gave evidence of any lesion of understanding, but who were under the dominion of instinctive and abstract fury, as if the faculties of affect alone had sustained injury” (p. 9). His observations were very controversial during this era, especially because a low intellect and symptoms of psychosis were the typical criteria for identifying mental illness (Stevens, 1993).

In the early 1800s, Benjamin Rush, an American psychiatrist, also documented confusing cases that were described by clarity of thought along with moral depravity in behavior. However, Rush (1812) went beyond Pinel’s more affectively based description and maintained that moral derangement was either a birth defect or was caused by disease. Rush believed this condition was primarily congenital. As he stated, “There is probably an original defective organization in those parts of the body which are preoccupied by the moral faculties of the mind”. In addition, Rush held that “it is the business of medicine to aid both religion and law, in preventing and curing their moral alienation of the mind”. The American psychiatrist maintained that the lack of morality was primarily hereditary, yet unstable environments were largely responsible for fostering its growth. Rush further claimed that offenders with mental defects were best treated in medical rather than custodial institutions. Benjamin Rush is recognized as one of the first to begin what has since become a long-standing practice of social condemnation toward individuals labeled psychopathic.

Monday, April 19, 2010

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).

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