Wednesday, December 17, 2008

Who Is A Criminal?

I'll admit this seems like an odd question with an obvious answer. Most people would say that a criminal is anyone convicted of a crime. However, there is a difference between someone who has merely been convicted of a single crime and someone with a pattern of criminal behavior. Repetitive criminals may be psychopaths or sociopaths. Fictional characters like Hannibal Lechter or Tony Soprano are good examples of sociopathic or psychopathic personalities.

It might be a bit disconcerting to know that people like this actually exist and that they've been around for a long time. In 1837 an English psychiatrist named James Pritchard wrote a book entitled Treatise on Insanity in which he described people who lacked the ability to form attachments to others and who were unable to experience normal human affection or emotions. These individuals had little regard for the feelings or rights of others, however they didn't have the hallucinations or impaired cognitive functioning that was seen in other psychiatric disorders. Dr. Pritchard coined the term 'moral insanity' to describe this disorder, which he felt was a defect in area of the brain responsible for moral reasoning. Around this time the American Journal of Insanity (which later became the American Journal of Psychiatry) published several individual case studies of homicide offenders, all of which were entitled "A Case of Homicidal Insanity". They were all essentially just case descriptions of murderers. The letters to the editor of the journal following these case studies debated the validity of 'moral insanity' as a mental illness. The difficulty was that the term 'insanity' implied that from a legal standpoint the criminal should not be held responsible or punished for his behavior. Eventually the term 'moral insanity' was dropped in favor of the term 'psychopath', a term proposed by a Nineteenth Century German psychiatrist.

More recently, the term 'sociopath' has been used instead of 'psychopath'. This latest change happened because people were getting confused by the 'psycho' part of the psychopathy label---psychopathy doesn't mean that the criminal is psychotic. Actually, neither sociopathy nor psychopathy are actual 'official' psychiatric diagnoses in that they can't be found in the Diagnostic and Statistical Manual (DSM). The DSM uses the term antisocial personality disorder (ASPD). Patients with antisocial personality disorder have difficulty with lying, impulsivity, repeated criminal acts, and impulsivity or irresponsibility. The majority of people with ASPD are not psychopaths. Psychopaths represent a minority of severely disordered people who lack emotional attachments or responsiveness. They are narcissistic and are unable to learn from experience. They lack empathy or remorse and are cold, cruel, callous people. This callousness is what distinguishes psychopathy from antisocial personality disorder.

There are a lot of people with antisocial personality disorder---about 3% of the United States population or nine million people. The exact prevalence of psychopathy may never be known because psychopaths usually only come to the attention of clinicians when they are caught committing crimes or when those around them coerce them into treatment. The most skillful psychopaths may not come to the attention of the law and may function successfully as politicians, religious leaders or heads of large corporations.

A screening tool for psychopathy was developed in the 1980's and has been widely used in research and forensic practice. Scores on the Hare Psychopathy Check List-Revised (PCLR-R) have been found to be useful for predicting violence and criminal recidivism. Psychopaths identified by the PCLR-R are being studied through functional neuroimaging in order to identify the physical basis for the disorder. These studies have shown that in psychopaths the part of the brain responsible for processing emotions works differently than in normal people. They also have different physiologic responses to emotion.

There is a genetic component to both ASPD and psychopathy as shown by adoption and twin studies. One large twin study has shown that for severe psychopaths as much as two-thirds of psychopathy can be attributed to genetics rather than environmental influences. For ASPD, the condition originates in childhood. A study done in the 1960's followed children from a mental health center who were referred for evaluation of their behavior problems. The study found that over fifteen years, one-third of the children with conduct disorder grew up to have antisocial personality disorder.

Can psychopaths be treated?

This is a tough question to answer. Psychopaths don't generally seek treatment voluntarily because they aren't bothered by their condition. They must be coerced into treatment or persuaded to participate by engaging their self-interest. For example, by emphasizing that treatment is a condition of parole and is necessary to stay out of jail or prison. Since psychopaths have difficulty learning from consequences, several treatment attempts may be necessary. The treatment must be designed to have open lines of communication between others involved in the psychopath's life in order to ensure truthfulness. There must be clear, consistent and firm boundaries between the patient and the therapist. Psychopaths with a high risk of violent behavior should only be treated in a secure and structured setting like a correctional facility. Psychopaths and people with ASPD are at increased risk of developing other psychiatric conditions such as mood disorders and substance abuse. Medication may be indicated for treatment of these co-existing conditions.

There is no evidence that psychopathy or ASPD can be cured. The goal of treatment is to minimize the impact of the conditions on others and on the patient. For example, one goal of treatment might be to minimize the risk of accidental injury by teaching the patient to recognize situations that trigger dangerous risk-taking behavior. Violence is another focus of treatment with psychopaths; violent behavior can be managed with administrative disciplinary procedures within the correctional facility or through the use of medication.

Specific treatment goals should be set up collaboratively with the patient so that expectations and treatment parameters are clear. The patient's self-identified treatment goal may also reveal his level of insight. When I asked one of my prisoners what he was working on in therapy, his answer was telling. "The truth," he said. "Telling the truth, it's something I've been working on for a while."

It's a beginning.


Anonymous said...

If skillful psychopaths did not exist, would the pyramids have been constructed?

Novalis said...

If the psychopath was telling the truth (about working on telling the truth), is that an unexpected therapeutic gain for a psychopath, or a hint that he isn't really a psychopath? Our shaky diagnostic categories always beg this kind of question.

I used to think that the term "sociopath" implied a belief that the person is actually more of a threat to society than to himself, but apparently it reflected a (questionable) belief that such persons are molded more by social conditions than by genetics.

I also wonder if psychopaths could be considered "morally psychotic" inasmuch as they have impaired "reality testing" with respect to basic human realities of empathy and ethics.

Anonymous said...

I also wonder if psychopaths could be considered "morally psychotic" inasmuch as they have impaired "reality testing" with respect to basic human realities of empathy and ethics.

Is that really an issue of reality testing? It seems to me, both empathy and ethics could be considered developmental issues.

Anonymous said...

The problem with the Antisocial Personality Disorder diagnosis is that it tends to be synonymous with "career criminal". Virtually anyone with a history of arrests will meet the APD diagnosis even if only a minority of them can be diagnosed as psychopaths as well. Pathologizing it doesn't make it into an actual disease.

Dr. Pink Freud said...

One thing that I find interesting is that, although we have a working definition (with some apparent reliability and validity), for psychopathy, that it is not included in the DSM.

Another thought (and Clinkshrink probably already knows this): Correctional officers and psychopaths tend to score virtually identical profiles on the PCLR, i.e., high need for control, risk-taking behaviors, etc.

Lastly (and this is a big one), why the artificial distinction between Axis I and Axis II disorders? Hmnnn...

Anonymous said...

I am a first year teacher working with a difficult population and I am convinced I have a number of future criminals in my classroom. The issues discussed have crossed my mind since some kids do bad things yet retain their humanity. However, I have some kids with very low levels of empathy and truth telling, and little regard for the feelings and rights of others. I am pretty sure some of these kids will end up incarcerated or dead both from the more empathetic group and the more psychopathic among them.

Anonymous said...

The problem with the Antisocial Personality Disorder diagnosis is that it tends to be synonymous with "career criminal"

Anonymous said...

I hate to say it but a lot of people on antidepressants, vicodin and benzo's act like psychopaths because their feeling are totally blunted on these meds. They don't seem to care what others think either. What say you?

Another thought, how many people are on medications and then are subsequently classified with a disorder, not the other way round? I know someone who was put on haldol and elevil for mild PPD and then was classified bipolar and scitzophrenic AFTER the heavy doses of medications. Is medication as a causative factor of adverse behavior being addressed?

Anonymous said...

A topic I have many opinions on. Unfortunately they mostly require empathy towards a sociopath and the unfortunate position they find themselves in.
I am undecided on the nature/nurture as many sociopaths demonstrate a severely traumatic childhood. There may be a dualistic process. But I do ascribe to the theorem that sociopaths are likely to have an anatomical altered hippocampi.

The only 'treatment' I have succeeded with in sociopathy is 'management' and basing everything on a cost/benefit exercise - extending the cost/benefit analysis into the abstract is difficult and takes much repetitive training almost by rote - just to get a sociopath to understand if they are negative to my colleague - I may feel negative towards them.
At least half of sociopathic behaviour is not as devisive as it appears - it is merely simplified reasoning at the level they are capable of and I don't think they have insight into their consequences.

My final point - sociopathic behaviour seems to exist on the autistic spectrum which demonstrates the same inability to empathically relate, socially interpret and think in the abstract.

I would suggest they are less culpable than society prefers to think.

Anonymous said...

Sorry, not relevant to this post, but I couldn't find another way to contact you: Wondering what you might have to say about controversy in Cleveland regarding death of Sean Levert, who was jailed for child support, denied his Xanax, and died six days later.

ClinkShrink said...

Stitches: Great comment. I've often wondered about the evolutionary contribution of sociopathy.

Novalis: My take on this is that even psychopaths can have some insight into the fact that there's something wrong with them. Therapeutic gain? I dunno, but a beginning maybe.

Romeo: Agreed. But defining the syndrome is the beginning for studying etiology. And we're seeing more support for the idea that there is a genetic basis for it, that there's some neurochemistry that sorts out ASPD from non-ASPD folks. So, maybe not a disease in the classical sense but maybe a developmental or genetic abnormality that predisposes to injury, leading to psychopathy.

Pink: I wasn't aware of the officer literature; I'd be interested in citations if you have them handy.

TP: I just read an article talking about how first grade teachers can identify future psychopaths. The first graders' parents couldn't or didn't identify their childrens' psychopathy.

Tainted: I think as far as culpability is concerned, the law will never exempt or reduce responsibility for psychopaths even if all the fMRI's in the world show their brains are abnormal. They might be spared the death penalty, but they'll not be found insane.

Anon: It's not good for someone to die of benzodiazepine withdrawal. I'm not sure what else there is to say about that.

therapydoc said...

Thanks. This is a great article. You'll be hearing from my readers, no doubt. YOU can answer their questions :)

Anonymous said...

Re the Levert case: Yes, certainly, bad that he died. But the questions I was wondering about include ...

-- Is what happened to Sean Levert a symptom, in your view, of a tendency by prison administrators to treat psychiatric illnesses as not 'real' -- or was it an exception to the norm?

-- The new Cuyahoga jail policy includes weaning prisoners off benzodiazepines. What's your take on this -- considering that these are relatively short-term prisoners, is it appropriate for a clink shrink to change the drug therapy? Is it appropriate for a shrink to go along with a policy designed, it would seem, less on therapeutic reasons than on convenience to the prison?

-- If a prisoner comes in with a current diagnosis, how much weight do you give that in determining your treatment? Do you defer to the previous doctor, or consider yourself to be starting from scratch?

ClinkShrink said...

Anon: Thanks for the clarification. I'm turning my response into a blog post.