Disturbing the Disturbed: Breaking All the Rules

Hey again – you may remember me: Nixie, that chick who was doing a series about mental illnesses called Disturbing the Disturbed?
Well, I’ve actually gotten myself into gear to work on the post! [cue gasps of shock]

As a note, for this post I looked exclusively at medical sites and Wikipedia (and checking Wikipedia’s references >_>) rather than other blogs and such. This is because I wanted to avoid the blunt force trauma that my skull would be subject to from slamming it into the desk repeatedly. The fact that looking up “psychopath” kept leading me back to a lot of sites on narcissism also played a part... but it was mainly the blunt force trauma.

This week, we cover Antisocial Personality Disorder, Sociopathy, and Psychopathy and the differences between them. Firstly, as you can see psychopathy is its own illness – being mentally ill, insane, or disturbing is not the sole criteria to be a psychopath. Let’s get to it, shall we?

FIRST: antisocial does not mean "doesn't like socializing". That is asocial. Antisocial is what goes against society's norms. Just had to say that.

Antisocial Personality Disorder (ASPD) is defined by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) as a personality disorder characterized by "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood".

While Sociopathy and Psychopathy are subtypes of ASPD, under the DSM and ICD they are used as synonyms. The specifics will be covered later.

The symptoms of ASPD are not so clean-cut as the symptoms of other mental illnesses as there are a variety of things that could be considered symptoms. So I shall list the diagnosis under the DSM-IV and the World Health Organization’s ICD.

Under the DSM-IV

• A) There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:
1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
3. impulsiveness or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;
• B) The individual is at least age 18 years.
• C) There is evidence of conduct disorder with onset before age 16 years.
• D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode. 

Note the explicit exclusion under section D – this is to cater for other disorders that on occasion have aspects of ASPD. As we know from my post on Bipolar Disorder, sufferers become reckless during a manic episode and may experiment with drugs and other socially deviant behaviour. I will cover schizophrenia in a later post.

Since evidence has indicated ASPD can be developed in children due to environmental as well as genetic factors, the limit on age has been included here. However, it has been found that those diagnosed with ASPD as adults were often diagnosed with conduct disorder as children.

According to these criteria, ASPD have a prevalence of 3% in males and 1% in females.

Under ICD-10 (where it is classified under the similar Dissocial Personality Disorder)

It is characterized by at least 3 of the following:

1. Callous unconcern for the feelings of others
2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations.
3. Incapacity to maintain enduring relationships, though having no difficulty in establishing them
4. Very low tolerance to frustration and a low threshold for discharge of aggression, including violence.
5. Incapacity to experience guilt or to profit from experience, particularly punishment.
6. Markedly prone to blame others or to offer plausible rationalizations for the behavior that has brought the person into conflict with society

There may be persistent irritability as an associated feature.
The diagnosis includes what may be referred to as amoral, antisocial, asocial, psychopathic, and sociopathic personality (disorder).
The criteria specifically rule out conduct disorders. Dissocial personality disorder criteria differ from those for antisocial and sociopathic personality disorders.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Now, since the World Health Organization decided to lump in ASPD with DPD but also specifically rule out some aspects of it, I’d advise that if you have need of this information (maybe for a book – since that is the only reason I’d sanction lest you’re a psychiatrist in which case you already knew this) to stick to the DSM-IV.

Millon also gives us five subtypes of ASPD:

• covetous antisocial – variant of the pure pattern where individuals feel that life has not given them their due.
• reputation-defending antisocial – including narcissistic features
• risk-taking antisocial – including histrionic features
• nomadic antisocial – including schizoid, avoidant features
• malevolent antisocial – including sadistic, paranoid features.

I will point out that the features of the “nomadic antisocial” are mostly benign – so, once again, no need to vilify.

Correlations and Causes

The fact is that a lot of other disorders are capable of coexisting with this one, and quite commonly do so: Anxiety disorders, Depressive disorder, Substance-related disorders, Somatization disorder, Borderline personality disorder, Histrionic personality disorder, and Narcissistic personality disorder. If alcohol is involved then there will be more frontal function deficits on neuropsychological tests (brain tests) that are greater than those associated with each involved condition.

Now, what’s interesting about ASPD is that there have been some correlations found with hormone levels. The roots of ASPD are said to be in genetics but are triggered by environmental factors, such as family relations. Traumatic events can lead to the disruption of the development of the central nervous system, thus changing what hormones are released when/where and changing the normal developmental patterns. A big player here is serotonin. In terms of function, serotonin is a mood moderator – tries to help against mood-swings and the like. Lower serotonin levels lead to higher levels of aggression and more instances of impulsiveness – two symptoms of ASPD.


Statistics
How common is ASPD? Well, apart from the aforemention DSM-IV related statistics, I have found a couple of contradictions on different sites in regards to prison populations. According to Wikipedia, a 2002 study found that ASPD was found in 47% of male prisoners and 21% of female prisoners. There is also a higher concentration than the norm within alcohol/drug treatment programs (Hare 1983).
However, according to Medicine.net, Wikipedia's Hare's Psychopathy Checklist page, and Internet Mental Health 50-80% of incarcerated individuals suffered from ASPD.

Either way, it is important to note that these statistics is about how many criminals have ASPD and not how many APD sufferers are criminals. After all, “disregard of lawful behaviours” is only one possible symptom of ASPD and with a minimal requirement of three of the listed symptoms it is more than likely that most ASPD sufferers do not present this symptom.
References for ASPD (I have just decided to list them in bulk because they overlap so much): the US National Library of Medicine, Medicine.net, PsychCentral, Internet Mental Health (which, despite the name and appearance, is pretty good provided you can navigate it - the search function is less than refined), and the Mayo Clinic (very good link, puts everything in layman's terms).


Now for Psychopathy... oh boy.

While Psychopathy was not used as an official term is refers to a personality disorder characterized by “an abnormal lack of empathy combine with strongly amoral conduct but masked by an ability to appear outwardly normal”. Note the use of the word “amoral” rather than “immoral” – while “immoral” means morally wrong, “amoral” is unconfined by the convention. They aren’t always doing things that are wrong or right – they just do the things that they want to do regardless of whether it’s considered one or the other.

(Think old fashioned Fair Folk – like the Seelie or Unseelie… mainly the Seelie.)

However, there is a bit of a problem - no-one has agreed on a set criteria for what a psychopath is. Silly, isn't it?


While I usually don't cover the statistics until later, it's one of the things that are agreed on so it seems fitting that I should open with them. While about 80% of incarcerated criminals were diagnosed with ASPD, only 11-20% of these were found to be psychopaths. Also, a study was recently conducted that found that 1 in 25 of today's business leaders could fit the criteria for psychopathy.

(Side note: psychopathy used to be the term used for any mental illness and was derived from the Greek words “psyche” (mind) and “pathos” (suffering) – suffering mind.)

The first fact is that psychopathy is a personality disorder characterized by a pervasive pattern of disregard/violation of the rights of others. Also included are a total lack of empathy and remorse, and being regarded as selfish, insensitive, dishonest, arrogant, aggressive, impulsive, irresponsible, and hedonistic.

As is expected of the subject, Wikipedia’s entry has a “check for neutrality” tag. So I will cover what is discussed in the Hare’s Checklist as it’s backed up by the medical journals. Now, there are a number of proposed assessments for psychopathy, but here I will only cover the Hare Psychopathy Checklist as it’s the most commonly used and relates it back to ASPD. Other tests include the Psychopathic Personality Inventory (PPI), and the Cleckley Checlist (Mask of Sanity – symptoms of those he deemed psychopaths)

(It is important to note that neither the World Health Organization or the American Psychiatric Association have given this mental illness formal recognition in their International Classification of Diseases (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).)
The most commonly used “psycho-diagnostic tool” used to assess pychopathy is Robert D. Hare's Psychopathy Checklist, Revised (PCL-R). It was originally a test based on two factors:

Factor 1: Personality “Aggressive narcissism:

• Glibness/superficial charm
• Grandiose sense of self-worth
• Pathological lying
• Cunning/manipulative
• Lack of remorse or guilt
• Shallow affect (genuine emotion is short-lived and egocentric)
• Callousness; lack of empathy
• Failure to accept responsibility for own actions

Factor 2: Case History “Socially deviant lifestyle”

• Need for stimulation/proneness to boredom
• Parasitic lifestyle
• Poor behavioural control
• Lack of realistic long-term goals
• Impulsivity
• Irresponsibility
• Juvenile delinquency
• Early behavior problems
• Revocation of conditional release

The two separate factors are supposed to aim at identifying the “affective deficits” and ASPD symptoms respectively. (the first factor also correlates with Narcissistic Personality Disorder)

It makes a point of saying that promiscuous sexual behaviour, multiple short-term marital relationships, criminal versatility, and “acquired behavioural sociopathy/sociological conditioning (Item 21: a newly identified trait i.e. a person relying on sociological strategies and tricks to deceive)” are correlated with either factor.

However, further studies have been editing and making suggestions about the criteria. For instance Cooke and Michie have indicated 3 factors, where the items for factor two that strictly relate to ASPD are removed from the final model, with the remaining factors being divided into “Arrogant and Deceitful Interpersonal Style”, “Deficient Affective Experience” and “Impulsive and Irresponsible Behavioural Style”. It should be noted that this particular model has multiple problems with it statistically speaking so it’s best to ignore it in favour of the most recent edition of the PCLR-R, where Hare adds a 4^th factor, consisting of those Factor 2 items excluded from the previous model. (The factors now examine the “Interpersonal”, “Affective”, “Lifestyle”, and overt “Antisocial features” of the personality disorder.)

Factors 1a and 1b are correlated with Narcissistic and Histrionic Personality Disorders, while 2a and 2b correlate with ASPD and criminality. However, to summarize, the criteria only highlight "What is missing, in other words, are the very qualities that allow a human being to live in social harmony".

Other facts of note are the only the minority of those diagnosed as psychopaths in institutions are violent offenders, and that while psychopaths are careless towards other people, they are also careless towards themselves. Also, psychopathy can coincide with anxiety disorders so “lack of nerves” isn’t a must-have-symptom.

Causes and precursors

Childhood precursors to psychopathy include a conduct disorder of some sort, or possibly Oppositional Defiant Disorder. (while the likelihood of a child with such a disorder becoming a psychopath is higher than the general population it must be stressed that the great majority do not become psychopaths as adults – or turn out to be disordered at all)

So far the most well-known test is known as the Macdonald triad: bedwetting (after the age of 12), cruelty to animals and firestarting. However, statistical analysis has proven the bedwetting to not be a significant factor. The other two factors, however, are still considered significant (as stated in my Classified Killers post).

Genetics also plays a role in what may bring about psychopathy, with studies finding that the “callous-unemotional traits” were strongly linked to genetics and were not influenced by the environment. This is also the belief of Robert Hare (of Hare’s Checklist) as expressed in his book "Without Conscience: The Disturbing World of Psychopaths Among Us" where he also expresses concern over the fact that the children of the psychopaths will be genetically predisposed to the disorder.
There are also hormonal links: psychopathy was also associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite). Studies have indicated that individuals with the traits meeting criteria for psychopathy show a greater dopamine response to potential 'rewards' such as monetary promises or taking drugs such as amphetamines. This has been theoretically linked to an increased impulsivity. I explained the effects of dopamine in Mad Love.

A 2010 British study found that high prenatal estrogen exposure, was a "positive correlate of psychopathy in females, and a positive correlate of callous affect (psychopathy sub-scale) in males". This makes sense, especially when combined with the facts in my Battle of the Sex Hormones post... which makes even more sense when combined with the theory that high levels of testosterone with low levels of cortiso contribute since testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction" and cortisol increases "the state of fear, sensitivity to punishment, and withdrawal behavior". However, while some studies support the cortisol theory, the testosterone one has not been tested yet.
I would suggest checking out the neuroscience area since that isn't a subject I am particularly adept in (or researched very much, or have people to consult with about it) so I don't want to misexplain something.


Finally, in an interesting side-note, psychopathy can be a side-effect of other diseases. For instance, Wilson’s Disease (the body’s inability to process copper) results in a mental illness – one such illness it can result in is psychopathy.

References for Psychopathy: Medicine.net, Psychopathy, Hare's checklist, two articles in Scientific American, and  significant overlap with the references for ASPD (since it is considered a subtype).



The term Sociopath tends to be used interchangeably with both ASPD and Psychopathy - it doesn't even get it's own page on most sites. It is claimed by David T. Lykken, a claim that seems to be supported by most sites, that the only difference between Psychopathy and Sociopathy is that the psychopath is born with the temperment that lead to their behaviour, while the sociopath was born with a rather normal temperment and are more a product of their environment. Basically, it comes down to nature verses nurture - the psychopath being when nature wins out over nurture and the sociopath being when nurture wins out over nature. (some places refer to Primary and Secondary Psychopathy, which fit the Psychopathy and Sociopathy I have covered respectively)
Information gathered on Sociopaths were from the same sites as ASPD and Psychopathy.




Now, while the series isn't over yet I won't be posting it consistently and will have other posts in between. This is a combination of (a) busy life, and (b) the larger amount of research to cover the disorders I plan on covering. To make for easier reading, I have added the tag "Disturbing the Disturbed" to all posts on the series.


I'd like to thank those who have been reading so far. :) Hope you've learnt something.