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Is the label «Psychopath» more a moral denunciation than a clinical
diagnosis?
Koshkina E.
Является ли ярлык «психопат» более морально осуждающим, чем
клинический диагноз?
Кошкина Е. Н.
Кошкина Екатерина Николаевна /Koshkina Ekaterina Nikolaevna - MSc (Master of Science) in Criminology and Criminal Psychology (University of Portsmouth, United Kingdom), г. Москва
Abstract: this article analyses diagnostic, subtyping and researches issues that lead to misunderstanding of what psychopathy is and who may be considered a psychopath. As well as why psychopathy has become a well-known label with the extremely negative meaning and widely usage by almost everyone.
Аннотация: статья анализирует проблемы диагностики, типирования и исследовании, которые приводят к неправильному пониманию того, что такое психопатия и кто может считаться психопатом. Равно как и то, почему психопатия стала хорошо известным и широко использующимся ярлыком с крайне негативным значением.
Keywords: psychopathy, ASPD, sociopathy, diagnostic issues.
Ключевые слова: психопатия, антисоциальное расстройство личности, социопатия, проблемы диагностики.
Psychopathy “was the first personality disorder to be recognized in psychiatry” [22, p. 28] and, in some ways, may be called one of the most famous psychological disorders together with schizophrenia and bipolar affective disorder. However, if people know of the existence of psychopaths, it does not mean that they understand the nature of this personality disorder very well. All the more so currently there is no such an official diagnosis as psychopathy or psychopathic personality, or psychopathic personality disorder, and even the defined difference between psychopathy and antisocial personality disorder (ASPD) is often blurred. Besides, “psychopathy and ASPD often treated as, but in fact, are not, equivalent diagnoses” [12, p. 22], which means that many persons, especially with history of violence, who are not actually psychopaths, are labelled as psychopaths due to their behaviour fitting in with the basic symptoms of ASPD that are listed in DSM-V. Furthermore, there still is a significant question of clear subtyping psychopathic personalities because not only plenty of individuals with psychopathic traits and behaviours exist, but also “groups of such persons may have little in common with each other” [30, p. 155]. Plus, “if subtypes are found, will all of them be ‘psychopaths’?” [25, p.186]. On condition that some of them, who may be labelled as ‘sociopaths’, are able to adopt social norms and be law-abiding citizens? In addition to not being an easy-diagnosing disorder, psychopathy generally cannot be treated effectively by therapy or somehow else, which makes it kind of a psychiatric nightmare.
So, what is psychopathy? Pinel [24] in some of his work described it as ‘mania without delirium with no cognitive dysfunction’; Henry Maudsley [20] classed it as ‘moral imbecility’ or ‘moral insanity’. According to Hart and Hare [12], it is “a form of chronic mental disorder associated with a specific set of symptoms” as “sense of entitlement, unremorseful, irresponsible, unconscionable, apathetic to others, affectively cold, blameful to others, manipulative, conning, disparate understanding of socially acceptable behaviour, disregardful of social obligations, and nonconforming to social norms” [8, p. 1]. McCord and McCord [21] supposed that the most noticeable trait of psychopathy is “diffusely unpatterned impulsive behaviour”. Hart and Hare [22] later specified that this is “persistent, frequent, and varied asocial and antisocial behaviour, starting at an early age”, and McCord and McCord [21] confirmed it by its own researching that so long as psychopaths are unsocial, their conduct “often brings them into conflict with society”. Maslow [19] wrote that psychopaths “have no love identifications with other human beings and can, therefore,
hurt them or even kill them casually, without hate, and without pleasure, precisely as they kill animals who have come to be pets.” Hare [8] described psychopaths as “remorseless predators who use charm, intimidation and, if necessary, highly impulsive and cold-blooded violence to attain their ends”. Thereby, it may be said that psychopaths are mentally ill due to their incapability to feel emotions or control their impulses, but at the same time, they cannot be considered insane due to there is no evidence proving that they cannot be rational and thoughtful, cannot reason, learn and manipulate on purpose.
However, any individual, which shows such symptoms, may be diagnosed with antisocial personality disorder (ASPD), according to DSM-V, or with dissocial personality disorder (DSPD), according to Chapter V of ICD-10, although the researches displayed that “most psychopaths meet the criteria for ASPD, but most individuals with ASPD are not psychopaths” [8, p. 2]. For example, Hare [8] writes that if assessing psychopathy in criminal population with the use of the Hare Psychopathy Checklist: Revised (PCL-R), then “between 15% and 20% of offenders receiving a score of at least 30, the cut-off for a diagnosis of psychopathy,” whereas “the mean scores for offenders in general and for non-criminals are around 22 and 5, respectively”. Blair [1] supposes that psychopathy and ASPD should be separated altogether due to the main problem with ASPD is “that allowed antisocial individuals with completely different personalities, attitudes and motivations to share the same diagnosis” [8, p. 2]. Besides, ASPD is the most common personality disorder among the criminals, and “almost any offender in a correctional setting is hypothetically entitled to a diagnosis of ASPD” [30, p.149], but there are also many psychopaths in non-criminal populations. For example, Cleckley [2] believed that “psychopaths could be found in society’s most respected positions: as doctors, lawyers, politicians, and even as psychiatrists.”
Lykken ([17] assured that psychopathy is one of two different subtypes of ASPD, and the second is sociopathy because psychopaths are impulsive, inclined to risk-seeking behaviour and incapable to adopt social norms whereas the sociopaths in general are temperamentally stable and much more affected by negative social factors like poverty and problems within their families. It is partly true so long as there are two key conceptions of psychopathy subtypes, and the first one is focused on “how the individuals with phenotypically similar symptoms differ etiologically” [25, p. 177]. According to Karpman [14], people with psychopathic personalities may be divided into two groups - ‘primary (impulsive or antisocial) psychopaths’, who are pure psychopaths, and ‘secondary (symptomatic or narcissistic) psychopaths’, who are sociopaths. Cleckley [2] remarked that “the true difference between them and those who continually go to jail or to psychiatric hospital is that they keep up a far better and more consistent outward appearance of being normal”. Nevertheless, Hare [10] thinks that sociologists may prefer the term ‘sociopathy’ as well as psychologists the term ‘psychopathy’ since the difference between them both “reflect the user’s views on the origins and determinates of the disorder”. The second conception is focused on “describing phenotypical differences among individuals with psychopathic traits by referencing comorbid traits of other personality disorder” [25, p. 177] and includes two major theories. The first theory is focused on “recurring patterns of overlap between psychopathic and other traits” [25, p. 177]. It is represented by Murphy and Vess’s four subtypes of psychopathy based on DSM-V’s Cluster B personality disorders - sadistic, narcissistic, antisocial and borderline. The second one is all about “psychodynamic personality organization” [25, p. 177], and represented by Millon and Davis’s ten subtypes of psychopathy, which are similar to Murphy and Vess’s four subtypes, but much more detailed and specific.
It was found by Herve and Hare [13] in the course of their joint research that “a very low base rate of manipulative psychopaths is in a recent sample of offenders”, but many primarily psychopaths “may be abundant in psychiatric samples”. So, the central question for subtyping researches is how to “identify ‘subclinical’ and ‘successful’ psychopaths in community and noncorrectional samples”, not “finding psychopaths under every stone” [25, p. 187], if, as a rule, psychopaths do not seek for help. Firstly, “people with personality disorder do not believe that they have a problem, it is the rest of world that has it all wrong” [15, p. 96], and secondly, “any control, however mild, irritates the psychopath, and he reject it” [21, p. 12]. What is more,
psychopathy is generally untreatable because “there is nothing ‘wrong’ with psychopaths in manner of a deficit or impairment that therapy can ‘fix’” [11, p.568]. Also, it still remains unknown what exactly provokes the development of psychopathic traits, which biological, sociological, psychological or neurological causes, although “the studies repeatedly indicate that painful treatment results in what has been called ‘aggressive action’” and many aggressive psychopaths were “severely rejected, physically beaten, and emotionally deprived by parents” in childhood [21, p. 11].
However, childhood abuse is not a privilege of psychopathic children only, so “deviant behaviour, then, is inadequate criterion of psychopathy” [21, p. 8], and it is not reasonably at all to label anyone as psychopath on the ground of his antisocial behaviour. Unfortunately, in the twentieth century “psychiatric diagnosis was an impressionistic art form and even experienced practitioners often could not agree in classifying the same patients except in a very general way”, and many “dangerous or persistent lawbreakers were labelled variously as psychopaths or sociopaths with negligible diagnostic consistency or clarity” [18, p. 3]. Moreover, Lewis [16] pointed that “the diagnostic concept at first called ‘moral insanity’ has been troubling” the psychiatrists due to “its outline will not be firm until much more is known about its genetic, psychopathology, and neuropathology”, and, undoubtedly, it gives a lot of scope for flight of fantasy. So, to be diagnosed with ASPD, for example, since there is no such an official clinical diagnosis as ‘psychopathic personality disorder’ and psychopathy is a subtype of ASPD, an individual must meet the requirements for this personality disorder which are listed as diagnostic criteria in DSM-V. Lykken [18] noted that “no special psychiatric knowledge or insight is required to make a diagnosis on the basis of these guidelines” because they focus on “disregard for the law, aggressive behaviours, and violation of social norms”, not on “the lack of empathy and the glibness associated with the most concepts of psychopathy” [27, p.231]. Therefore, any person, if his behaviour does fit in with obvious symptoms of ASPD, may be theoretically labelled as a ‘psychopath’, not being psychopath in point of fact. Hare [9] and his colleagues “have taken great pains to differentiate between psychopathy and ASPD when clinicians use the labels as if the constructs they measure were interchangeable”.
Gunn [3] wrote that “in such cases we are sometimes told that the patients have a ‘dual diagnosis’” and, apparently, “the label ‘psychopathic’ is not being applied to assist with the understanding of the patient’s psychopathology, it is simply used as a mechanism to reject these patients”. In other words, this label implies in some ways that this patient is ‘untreatable’. It leads to “a stereotyped approach to treatment that ignores or misses the important variations among patients” [3, p. 33] despite the fact which says that if “some treatments that are effective for other offenders are actually harmful for psychopaths, it does not mean nothing can help” [11, p. 568]. Harris and Rice [11] supposed that “tightly controlled behavioural programs with contingences remain in effect both inside and outside institution” for antisocial and aggressive psychopaths who cannot control their impulses dangerous for the society in whole or small local communities. What is more interesting, most researches and mental health professionals are all reluctant to discuss psychopathic children although the specific personality traits “begin to manifest themselves in childhood” [9, p.194]. So, if there is a chance to influence the development of psychopathy, it might be, probably, done at an early age even if the problem is complicated by “a general failure to differentiate the budding psychopath from other children who exhibit serious emotional and behavioural problems”[9, p.194]. From this perspective, the term ‘psychopath’ seems to be “a trigger for rejection” [3, p. 95], although mental hospitals are supposed to be “staffed by experts in curing diseases” [30, p. 154] who are meant to help individuals suffering from psychological problems. Or it is “a largely moral term” [3, p. 95], which symbolises helplessness what psychiatrists might feel facing the compound cases than a clinical diagnosis itself.
That is why Gunn [3] guessed that ‘psychopath’ has become almost synonymous with ‘badness’ - “a powerful concept that is unhelpful in medical science” where “the morality of patient’s symptoms or behaviour ought to be irrelevant”. Toch [30] wrote that he recalled “not a
single instance in which my understanding of an offender would have benefited from adjudging the person a psychopath”. Nevertheless, it is very interesting that when a psychiatrist called a patient, who has been rated by PLC-R high enough to reach a conditional psychopathy cut-off, a psychopath, “other people would call this patient a ‘really bad person’” [3, p.36]. Besides, the psychopathy literature tended to “stigmatize almost any offender about whom there was concern or trepidation” [30, p.155]. There were “sexual psychopaths” who are now “sexually violent predators”, there were drug abuse offenders who have been described as “overwhelmingly psychopathic”, and, of course, there always were serial killers who “have been perennial candidates for ‘psychopath of the year’” [30, p.155]. Historically, the term ‘psychopathic’ “was introduced to fully cover all forms of psychopathology” [3, p. 34]. However, nowadays, according to Smith [28], this term means “one whose persistently antisocial and asocial behaviour cannot be primarily attributed to mental subnormality or psychosis, and stimulates society to treat him” as a really bad person who may not be a psychopath at all. Even if this individual was diagnosed with ASPD due to “diagnoses, like all human judgements, can be mistaken” [21, p. 188]. The Stevens study [29] has shown that “the clinicians used the diagnosis of ASPD in more than half of their diagnosable cases, and opined that the diagnosis could be used in these percentages with the entire inmate population”. Thereby, for them, it is just a label.
Summing up, it should be said that psychopathy is “a form of personality disorder with a distinctive pattern of interpersonal, affective, and behavioural symptoms” [12, p. 22], which may be identified with Robert Hare’s PLC-R. The DSM-IV’s and ICD-10’s guidelines as before do not make any distinctions between antisocial personality disorder, or dissocial personality disorder although there are a solid theoretical base and some approximate typologies of psychopathic individuals. Furthermore, antisocial, asocial, impulsive and aggressive behaviour together with lack of remorse, irritability and irresponsibility are considered good reasons to officially diagnose with ASPD any person who acts this way regardless of “many other deviants exhibit dangerous behaviour, but they do not share the character structure of the true psychopathic personality” [21, p. 8]. Besides, many psychopaths may be found in any noncriminal populations, for example, so called ‘corporate psychopaths’, who are capable to live in society conforming to its regulations, and not to be diagnosed with any personality disorders or something like this. The existence of the groups of individuals with psychopathic traits and behaviours, which have little in common with each other leads to the misunderstanding of the nature of psychopathy.
Since psychopathy is untreatable in general, the term ‘psychopath’ seems to be more “a trigger for rejection” [3, p. 95] than a clinical diagnosis, or else “a largely moral term” [3, p. 95] that is a stereotyped and wrongful reflection of the meaning of such words as ‘badness’, ‘incorrigibility’ and ‘monstrous’. Shortly, for the public and some clinicians being ‘psychopath’ implies to be incredibly bad, to be something what cannot be ‘fixed’ and, thereby, strongly needs to be isolated from the others by incarcerating in high security mental hospital or prisons for life. Nevertheless, the ways to help them controlling their impulses have been already found and tested, and in the nearest future, through developing knowledge of psychopathy may be found the effective ways to reduce its displays. Then, probably, the term ‘psychopathic’ of itself as well as associated with it the terms ‘psychopath’, ‘psychopathic disorder’ and ‘psychopathic personality’ stops being a convenient label for a moral denunciation.
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