A Wikipedia printout on Antisocial Personality Disorder (ASPD) and article in Scientific American Mind (“Inside the Mind of a Psychopath,” September/October 2010) interested me in the topics of ASPD and psychopathy. I wanted to see how I scored on the Hare Psychopathy Checklist- Revised, the standard for clinical evaluation. I was also interested in it as a social phenomenon- how many around me were psychopaths? How were they dealing with it, and how were they treating others? What I found is consistent with the psychological authority on this topic, but different than you might expect.
First, I am in prison for bank robbery. I lost my job in 2005, and committed what was for me an impulsive and suicidal act. I had prior disappointments in life, and had to drop out of college because I couldn’t afford it. It was also an act of revenge, because I lost the job due to a drug test, one more reason that I hated the system. I had received psychiatric care before this, but unfortunately had been prescribed a less efficacious drug for bipolar disorder, Depakote, rather than lithium. Counseling did not really affect the issues that I had, including antisocial personality disorder, which was undiagnosed.
I tried the PCL-R on myself after obtaining it in Wikipedia. At first glance, it appeared too brief. I was expecting paragraph-long questions and a deeper analysis of a person’s past. As I applied it, though, I found that the 20 questions in 3 categories summarized the condition well.
A person is rated as a 0, 1, or a 2- if the statement doesn’t apply, applies somewhat, or fully applies. The items fall under the headings: (1) Personality “Aggressive Narcissism,” (2) Case History “Socially Deviant Lifestyle,” and (3) traits not correlated with either factor. The most recent version of the Hare PCL-R refines this into four factors- the interpersonal, affective, lifestyle, and overt antisocial features of the disorder. The latest version was not available to me at the time of this writing.
The test is structured as follows:
Factor 1: Personality “Aggressive Narcissism”
1. Glibness/ superficial charm
2. Grandiose sense of self-worth
3. Pathological lying
4. Cunning/manipulative
5. Lack of remorse or guilt
6. Shallow affect (genuine emotion is short-lived and egocentric)
7. Callous/lack of empathy
8. Failure to accept responsibility for own actions
Factor 2: Case History “Socially Deviant Lifestyle”
9. Need for stimulation/proneness to boredom
10. Parasitic lifestyle
11.Poor behavioral control
12. Lack of realistic long-term goals
13. Impulsivity
14. Irresponsibility
15. Juvenile delinquency
16. Early behavior problems
17.Revocation of conditional release
Neither factor:
18. Promiscuous sexual behavior
19. Many short term marital relationships
20. Criminal versatility
Factor 1 items address interpersonal and affective functioning, and are correlated with narcissistic personality disorder. A high score on Factor 1 only means a person should be evaluated for one of these two other disorders. Factor 2 corresponds with a diagnosis of antisocial personality disorder independently. High Factor 2 scores are associated with reactive anger, poor self-control, and criminality.
I scored low on Factor 1- I had a lot of 0’s and 1’s to items like superficial charm and pathological lying- if I have any charm, it’s genuine, and I do not have any propensity to lying. As far as grandiose sense of self-worth, I was more moving in the other direction. I got a two for this section.
Factor 2, on the other hand, was right on the mark. This is the criminally-minded part of psychopathy. I scored a 2 on need for stimulation/proneness to boredom, 2 on early behavior problems, a 2 on juvenile delinquency, and a 1 on the rest (except for probation violations, which didn’t apply). Some of the 1’s were for poor behavioral control, impulsivity, and irresponsibility. My point total was 11 for Factor 2. Plus the “other” category, I got a total Hare score of 17.
This identified me as a person with possible ASPD instead of psychopathy, which was a relief to me. No sane person wants to be cunning and manipulative, remorseless, or lack empathy or the capacity for real emotion (or do they? More on this later).
The DSM-IV-TR defines ASPD as:
A) There is a pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15, 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. Deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
3. Impulsivity 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 indicted 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 18 years of age.
C) There is evidence of conduct disorder with onset before age 15.
D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.
Clearly, there is a big difference between ASPD and psychopathy. I qualified for the former diagnosis before, and at some time during, my incarceration.
A central question in both ASPD and psychopathy is can the person change? Kiehl and Buckholtz have written, “In a collective throwing up of hands, psychiatrists have long written psychopaths off as beyond help. But now that science is unraveling the mechanisms behind the disorder, it is time for that attitude to change.” Indeed, it appears that with the right medication and change in environmental factors, great improvements in these personality disorders can be realized. Also, as the person ages, many items from the Checklist cease to apply as the person matures.
Is lithium an effective treatment for psychopathy and ASPD? In my case, the answer is an unequivocal yes. I took another look at my answers on Hare’s test, and rescored them based on my characteristics before lithium. My score jumped to a 26- almost a 10 point gain. Lack of remorse or guilt went from 1 to 2, as did failure to accept responsibility. Most of the antisocial items from Factor 2 went from 1 to 2 as well. I know that the 17 I scored now reflects my current status, the way I have been for the past three years.
My crime occurred during a manic episode, but there was plenty of evidence for the onset of ASPD before the bipolar disorder. Individuals suffering from either psychopathy or ASPD may also have an underlying Axis-I disorder, such as bipolar disorder or anxiety. Treating this may pave the way for positive changes in their personality, and a more healthy lifestyle. Even if they have no other diagnosis, mood stabilizers and antidepressants target a number of items on the PCL-R very well (i.e., lack of empathy, need for stimulation and poor behavior control). There may be other medications that will prove more effective than lithium, and I believe that new treatments and clinical trials should be a top priority for the psychiatric profession.
Most psychopaths and ASPD suffers can improve, especially if their behavior and mindset was significantly worsened by their environment. Prison is a hard place to attempt this, due to an atmosphere of constant conflict and strict regimentation, but it can be done. Many inmates get psychiatric care (or the proper psychiatric care) in prison for the first time. Notably, I have never seen a psychologist in prison test or diagnose an inmate for antisocial disorder or psychopathy. I didn’t even know ASPD existed until I read The Complete Idiot’s Guide to Psychology. Psychiatric treatment in prison may be limited to superficial care in some aspects, but this could be greatly improved as to these two diagnoses. Kiehl and Buckholtz noted that between 15 and 35 percent of U.S. prisoners are psychopaths, and Hare estimated that 80-85% of prisoners have ASPD.
Treatment is not just a necessity from a mental health perspective- it directly relates to public safety as well. The 20% (or so) of psychopaths in prison account for 50% of all the most serious crimes committed. Kiehl estimated the expense involved with prosecuting and incarcerating psychopaths and the harms they inflict on victims at $250-400 billion a year.
Kiehl stated that “No other mental health problem of this size is being so willfully ignored.” He and Buckholtz estimated that that there are 500,000 psychopaths in prison, and another 250,000 living freely. “Helping them manage their impulsivity and aggression could protect many innocents. Until now, though, few efforts have been made on that direction. Billions of research dollars have been spent on depression; probably less than a million has been spent to find treatments for psychopathy.”
This is due to the misconception that nothing works, or perhaps the greater profit potential for drug companies. Michael Caldwell, a psychologist at the Mendota Juvenile Treatment Center in Madison, Wisconsin, has obtained results with intensive one-on-one therapy (called decompression). This therapy seeks to break the cycle of crime leading to punishment which in turn leads to further crime. One thing I have found effective myself and recommend, is to find activities that satisfy a person’s high need for stimulation- working out, extreme sports, martial arts, and going to dance clubs. Doing this diverts that person’s antisocial impulses into a socially acceptable form that provides the same (or similar) fulfillment. To that extent, I found rehabilitation in prison by earning my paralegal certificate, working as a law clerk, mixed martial arts, and physical fitness. These things helped build self-control and a sense of pride that was missing before. All were accomplished without any aid from officials. One thing that was key to my recovery was the love and support of family.
In addition to myself, I tested six friends in my dorm using the Hare Checklist. Their scores in descending order were 34, 31, 28, 27, 25, and 19. Persons profiled were in prison for a variety of violent and property crimes, except the lowest scorer (19), who was in for drugs and theft. We were in a position to judge whether the responses were accurate, being around each other day in and day out. None seemed like the “classic” psychopath, a detached and violent individual only concerned with himself. However, it is clear that psychopathy does not always manifest itself in this way, even in people who score over 30. Kiehl and Buckholtz have noted that “The appearance of normalcy- the so-called ‘mask of sanity’- has bedeviled the study of psychopaths. Though guilty of the most erratic and irresponsible, sometimes destructive and violent behavior, they show none of the classic signs of mental illness.
When pressed, most of the six agreed that they did not want to be psychopaths. Interestingly, the one who scored the highest (34) and another individual previously evaluated by a mental health professional at 36 did. There does seem to be a line in the sand at 30 that differentiates the illness- or puts it into a higher category.
There was one exception- the person who scored 31 was not happy with this and told me that he did not like the way he was. This man was a good, loyal friend, and except for the emotional detachment and antisocial tendencies would be normal.
The true psychopaths had case histories that were fantastic beyond all criminal design. I saw not only criminal versatility, but a pathological inability to learn from their mistakes. Both characteristics were also present in a friend who has spent half of his life in prison, but exhibits no violent tendencies and has an extensive record of burglaries and grand thefts. The percentage of those above 30 on Hare’s scale was 26%, exactly in line with the figure of 15-35%.
Two individuals (the 25 and 27) scored much greater on Factor 2, placing them as possible antisocial personality disorder. I noticed a far greater suicidal ideation among them in keeping with what is known about people with ASPD. I did not have enough data to confirm whether those with high Factor 1 scores (or both Factor scores) were insulated from suicide, but I did find it notable that the friend who scored 34 had attempted suicide in a dramatic way. As for myself, my crime was committed with an indifference to my own life or death, and I had attempted suicide once in prison.
Throughout my prison sentence, I have noticed the prevalence of “classic” or “perfect” psychopaths. These are individuals who score at or near 40. Those who are unfamiliar with this field might call them the picture of evil. Aggressive and thoughtless, they charm, manipulate, and extort those around them- and often resort to violence. Thankfully, their prevalence is about (I estimate) 2-4% of the prison population. Generally, they are not open to psychiatric help, and perhaps some behavioral management strategies and a positive reward system could reach them.
All six individuals that I evaluated were of at least average intelligence, some well above average. I could not connect high Factor 1 scores with high intelligence or achievement because I did not have data on IQ scores. Likewise on socioeconomic status, most came from the lower end of the spectrum and I could not establish any patterns there.
It appears that psychopathy is strongly genetic, and ASPD a combination of genes and environment. Kiehl proposed that psychopathy emanates from a lack of brain matter in the paralymbic system, a network of brain centers involved in emotion, goal-seeking, motivation, and self-control. On the nurture side, it appears there is also a window during childhood development where conscience is learned, which narrows down the causes of psychopathy from both paths.
Despite the fact that psychopaths “have a learning disability that impairs emotional development” (Kiehl and Buckholtz), the American Psychological Association does not recognize psychopathy as a separate disorder from ASPD. It does not make sense to treat both the same. Only 1 in 5 of those with ASPD are psychopaths. They require a treatment that takes into account their interpersonal and affective disorders.
Why does the APA maintain this stance? Mostly, it has to do with accuracy of diagnosis, including the difficulty of scoring a person (who may be less than forthcoming) on Factor 1 of the scale. It may also have to do with political correctness, the psychological authorities’ reluctance to use a term that may be stigmatizing. Certainly, researchers and experts in the field know that we have not banished the terms psychopathy and sociopathy to the past, and are still trying to understand and treat this illness. To this end, Robert Hare, Kent Kiehl, and Joshua Buckholtz deserve our praise.
Whether using fMRI, genetic, or behavioral studies, psychologists are making great progress toward understanding and treating this devastating disease. Perhaps as they achieve more notable successes, or psychopathy comes into the mainstream through the crimes psychopaths commit, the APA will be forced to add the disorder to its classification scheme. We will all be better off if the illness becomes treated like bipolar disorder or depression. As Kiehl and Buckholtz concluded, “As scientists continue to describe the brain dysfunctions of psychopaths, the revelations promise not only to aid disturbed individuals but to bring sanity to society. […] When lawyers, jailers, psychiatrists and others begin to see psychopaths for what they are- not monsters, but people whose emotional disabilities may cause them to act monstrously- we will all be on the path to a safer future.
Sources:
“Inside the Mind of a Psychopath,” Kent A. Kiehl and Joshua Buckholtz, Scientific American Mind, September/October 2010.
Hare Psychopathy Checklist-Revised, http://en.wikipedia.org/wiki/Hare_Psychopathy_Checklist (accessed 5/7/11)
Antisocial Personality Disorder, http://en.wikipedia.org/wiki/Antisocial_Personality_Disorder (accessed 9/9/10)
