Murderous Minds (10 page)

Critics suggest that it is even possible to read up on some mental disorders that aren’t really mental disorders within the volume. They say these are more like traits, eccentricities, or even perhaps extreme, but nevertheless normal, examples of human behavior. They cite Hoarding Disorder, Oppositional Defiant Disorder (“A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness …”), Binge-eating Disorder, and Disruptive Mood Dysregulation Disorder (“chronic, severe persistent irritability … frequent temper outbursts”) as examples.

The same critics often fail to mention that any behavior or syndrome that causes pain and suffering, or that interferes with or prevents someone from living a satisfying and productive life, is a legitimate subject for psychiatric or medical care, and thus worthy of inclusion in the manual. The problem may affect only the person diagnosed with the disorder, or it may extend to others, including family members and society itself, as is the case with antisocial personality disorder.

Another criticism is that the American Psychiatric Association is too heavily influenced by pharmaceutical companies who stand to benefit if more pills are prescribed for more disorders. One study concluded that 56% of the 170 mental health professionals contributing to the DSM–IV, which was published in 1994 and revised in 2000, received money from the pharmaceutical industry in the form of research funding, consultancies, or
speaking fees.
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Reportedly, 70% of the contributors to the DSM-5, which appeared in 2013, have such ties.
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The description of antisocial personality disorder in various editions of the DSM and its relationship to psychopathy has been just as great a source of controversy over the years.

You might think that the term “sociopath” would be a good label for people with antisocial personality disorder (ASPD), the closest diagnosis to psychopathy the American Psychiatric Association recognizes. In fact, the organization considers sociopathy, psychopathy, and the World Health Organization’s version, dyssocial or dissocial personality disorder, to be the same thing as ASPD.

The criteria for antisocial personality disorder and other personality disorders, including borderline, paranoid, narcissistic, obsessive-compulsive, etc., listed in the previous edition of the standard manual for classifying mental disorders, the DSM-IV, have not changed in the most recent edition. In fact, it hasn’t changed much since the DSM-III came out in 1980. Does this mean psychiatrists have made no progress in recent decades in understanding personality disorders, including the one it says is the same thing as psychopathy?

It depends, of course, on whom you ask. Not surprisingly, some psychiatrists see encouraging progress. In 2012, for example, Jerold Heisman and Hal Strauss, authors of
I Hate You, Don’t Leave Me: Understanding the Borderline Personality,
recognized enough progress in understanding this disorder to release an updated edition of their classic 1991 book. For over twenty years, their book was one of the most popular sources of information for the general public about people burdened with a poor sense of identity who often are self-destructive, are afraid of being abandoned, and experience rapid mood swings. And psychiatrist David Kupfer, M.D., the chair of APA’s DSM-5 Task Force, sees progress in our understanding of schizophrenia, bipolar disorder, and autism spectrum disorder based on the experiences psychiatrists have gained studying and treating these disorders, despite the inability of neuroscientists so far to identify the neural basis of 97 percent of the mental disorders listed in the DSM-5.

Others, including the Director of the National Institute of Mental Health, Tom Insel, M.D., a former Professor of Psychiatry at Emory

University, are not impressed with recent psychiatric progress. Insel has largely given up on the DSM-5—and the approach it takes.

The DSM, Insel insists, lacks scientific validity. He sees it as a good dictionary, one that provides “reliability” [his use of quotes] since its common use ensures that mental healthcare providers are all talking about the same thing when they mention a diagnosis. The problem the Director sees is the lack of objective laboratory measurements for making the diagnoses in the first place. It still relies on lists or clusters of clinical symptoms to make diagnoses. “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,” Insel blogged.
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He wants to spur psychiatric research into the 21st century by promoting research in genetics, brain imaging, and cognitive science to transform the way mental illnesses are diagnosed. The NIMH, which funded more than $912 million in research project grants in 2013, will no longer award grants based on DSM classifications. Instead they “will be supporting research projects that look across current categories—or sub-divide current categories—to begin to develop a better system.”

It may take years, even decades, to come up with reliable clinical tests that will be able to accurately diagnose mental disorders from a neurological standpoint. Insel knows this and wants to get started finding better ways to diagnose mental disorders based on biological markers. Unfortunately, neuroscience, the basis of biological psychiatry, is way behind older fields of biology like physiology in understanding the fundamentals of its subject. Before progress is likely in mental health research, there will need to be considerable progress in understanding the brain itself. Despite a pop-neuroscience industry that today tacks “neuro” onto seemingly anything: economics, ethics, law, marketing, semantics, education, energetics, fitness, fuel, drinks, and more, the field is very young and researchers are still struggling to understand basic principles of brain organization and function and how it relates to behavior.

This is why psychiatrist Kupfer as chair of the DSM-5 Task Force responded to psychiatrist and NIMH Director Insel by noting that we have been waiting for biological and genetic markers of mental disorder for at least forty years and we are still waiting. Efforts to provide these markers are obviously important. “But they cannot serve us in the here
and now, and they cannot supplant DSM-5,” Kupfer wrote in an APA news release in response to Insel’s broadside attack. “In the meantime,” he concluded, “should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.”

The field of psychopathy research is somewhat entangled in this complicated controversy. For the most part, academic researchers are convinced that antisocial personality disorder as defined in the DSM-5 does not fully capture all of the features and personality traits of psychopathy as they conceive of the concept. The majority of people diagnosed with antisocial personality disorder are given that diagnosis because they have displayed behaviors that are criminal, antisocial, and in some cases violent. But these behaviors, the criteria for diagnosing the disorder, don’t address some of the core, defining features of psychopathy, such as lack of empathy, grandiose sense of self-worth, and emotional poverty (shallow affect). Measuring psychopathy, by contrast, involves determination of personality traits
based
on past and present behaviors, not on the behaviors by themselves. Consequently, you won’t find any indication in the following diagnostic checklist that a prisoner with antisocial personality exhibits superficial charm, fearlessness, lack of empathy, lack of a conscience, or lack of emotional depth, for example.

The U.S. Justice Department’s Bureau of Justice Statistics reported in July 2013 that there were around 1,571,013 inmates in federal or state prisons in 2012.
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This is 27,770 fewer inmates than were locked up in 2011. The promising drop, the third in a three-year streak, unfortunately doesn’t mean the incidence of criminal psychopathy or antisocial personality disorder is declining.

For every one of the million or more adult male criminal psychopaths you are liable to encounter behind bars, on probation, on parole, or on trial, you will meet two or three non-psychopaths with criminal records who have ASPD.
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In other words, the six or seven million males in the U.S. judicial system include different types of people who commit crimes for different reasons. An estimated 16% of them are psychopaths,
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but as many as 80% of them have antisocial personality disorder. These figures mean that around two or three million criminals eighteen years or older in the U.S have demonstrated three or more of the following behaviors:

• “Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
  
• “Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
  
• “Impulsivity 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.”
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It turns out that most criminal psychopaths meet the criteria for ASPD listed above, “
but most individuals with ASPD are not psychopaths
[original emphasis]” according to Hare.
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When criminals with ASPD also have psychopathy in their personality profile, the results aren’t good news for the rest of us. Summarizing their ongoing legacies, King’s College London researcher Sarah Gregory and her collaborators note that such men “begin offending earlier, engage in a broader range and greater density of offending behaviors, and respond less well to treatment programs in childhood and adulthood compared with those with ASPD without psychopathy.”
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The final requirement for a diagnosis of ASPD is evidence of conduct disorder before age 15. “Conduct disorder” is a diagnosis given mainly to children and teens whose antisocial behavior goes far beyond the typical behavioral problems that the parents of less troubled children have to deal with. It involves serious and troubling behaviors like:

• Aggression to people and animals. Examples include physical fighting, bullying, intimidation, threatening behavior, use of a weapon to harm another, and cruelty to people or animals.
  
• Destruction of property. Setting fires and/or otherwise destroying property.
  
• Deceitfulness or theft. Conning others, breaking into others’ property, and stealing.
  
• Serious violation of rules. Running away from home, skipping school, often staying out at night after starting this behavior before age 13.
  

You don’t need to go to prison to become familiar with ASPD. If you were to hang out with a gang in Great Britain, for instance, you would find that eight or nine out of every ten of your companions would have antisocial personality disorder.
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All children with conduct disorder, of course, do not become psychopaths, but many criminal psychopaths show some of these behaviors growing up.

With the publication of the DSM-5, this subgroup may be recognized with a new addition to the psychiatric manual’s description of conduct disorder. The latest version includes the characteristic “Callous—lack of empathy.” Recognizing that a subgroup of children with conduct disorder have a cold, uncaring outlook and a nearly complete disregard for the feelings of others—including others they have harmed—is an important step toward someday including the core features of psychopathy in the descriptive entries of the standard psychiatric manual for diagnosing mental disorders.

Another indication that clinical psychiatry and academic research in time might better define the concept of psychopathy is found toward the back of the DSM-5 in Section III: Alternative DSM-5 Model for Personality Disorders. These descriptions are based on the assumption that personality traits are present in different degrees in different people. Instead of using an all-or-none approach by trying to nail down a diagnosis by determining whether a particular trait is present or not, this approach, which psychologists refer to as a dimensional approach, tries to determine how much of a personality trait is present in an individual. Among the alternative models of personality disorders in the DSM-5 you can find a description of antisocial personality disorder with psychopathic features.

Christopher Patrick, who served as a special advisor to the committee that wrote the personality-disorder section of the manual, says this specifier incorporates key features of his Triarchic model of psychopathy: boldness,
meanness, and disinhibition. So why isn’t this newer, dimensionally based model of psychopathy in the front section of the DSM-5, the section clinicians will refer to when they diagnose troublesome people seated across from them in the office or prison exam room?

The workgroup rewriting the personality section didn’t spend any time revising the older version and ran out of time working on the revised version. “They ran out of time at the very last minute [and] had the rug pulled out from under them,” Patrick said. The Trustees, who had overall responsibility for the rewrite, “were really nervous about this new system,” he recalled. They didn’t feel comfortable putting it into the main manual, so they relegated it to a back section.

Perhaps we shouldn’t be surprised that progress in this field often appears to crawl. After all, it represents an attempt to understand what distinguishes a human being with a conscience from one without a conscience. Insights into the traits we have come to identify with psychopathy, and which appear in both older and emerging models of the disorder, can be traced in medical writings all the way back to Philippe Pinel around the turn of the 18th century. Progress building on Pinel’s description of people with “insanity without delirium” was sluggish for hundreds of years. Jeff Feix, Ph.D., Director of Forensic and Juvenile Court Services at the Tennessee Department of Mental Health, estimated in 2006 that “the concept of psychopathy has undergone more study and refinement in the past 20 years than in the previous 200… .”
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