Tag Archives: psychosis

What’s in a name? The fickleness of sociopathy: Ideas, the suspension of the conscience, and why psychopathy is completely different

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There is one question that can often haunt research on mental illness and mental disorders. Simple as it may seem, “What should we call it?” can often pose no end of obstacles, and result in long drawn out debates in the mental health and medical profession. One reason for this is that certain maladies often have numerous dimensions, and symptoms can present differently in those afflicted. Typically, through extensive research, diagnostic criteria are established under the banner of one name; pick up the DSM-V or the ICD-10 and you’ll see the names for all kinds of illness and disorder, with thorough lists of all the symptomatology that is now accompanied and unified under a common name. But these symptoms are often present in other conditions, and present in the patient to different extents. Rendering a diagnosis is indeed a tough challenge for any mental health professional.

 

Another reason that makes it difficult to name a particular mental health phenomenon, is that there is sometimes an inclination for the name to include the developmental origin. This struggle is perfectly captured in the history of psychopathy research. Cleckley, arguably the first psychiatrist to make strides in classifying psychopathy, writing in the 1940s devoted many chapters in his book, The Mask of Sanity, to discussing how the term and the individual were currently seen by the mental health establishment.

 

Every physician is familiar with the term psychopath, by which these people are most commonly designated. Despite the plain etymological inference of a ‘sick mind’ or of ‘mental sickness’, this term is ordinarily used to indicate those who are considered free from psychosis and even from psycho-neurosis.

Cleckley, The Mask of Sanity[i]

 

Clearly, in the mental health profession, a term denoting a ‘sick mind’ is not particularly useful in attempting to make a diagnosis, as it perhaps captures every possible mental malady that can afflict the human brain. However, the term does appear to capture those who are free from psychosis and psycho-neurosis, while still indicating that something is awry within these individuals. The truly psychopathic are renowned for behaving in socially pleasing ways, at least temporarily, before they are implicated in acts of antisocial behavior, sometimes even downright grotesque or horrendous behavior. This nature of the psychopath puzzled mental health experts and laypeople alike, as they pondered how one person could exhibit such extremes of behavior, sometimes in a short space of time.

 

Later, the term ‘psychopath’ clearly evolved and took on new meanings as research on this dangerous personality disorder progressed in the twentieth century. As the esteemed psychologist, Robert Hare, pointed out:

 

[Those] who feel that psychological, biological, and genetic factors also contribute to the development of the syndrome[,] generally use the term psychopath.

 Hare, Without Conscience[ii]

 

Hare stated this in contrast to those who were using the term ‘sociopath,’ who according to Hare were convinced that social factors and early experiences were responsible for the manifestation of this particular disorder, and subsequently this particular type of person, in society.

 

This appearance of two names for the same disorder (psychopathy/sociopathy), and the same person (psychopath/sociopath) becomes problematic. Not only is having two different names for the same condition a little redundant, but the developmental origins, the initial reason for having the two different terms, all belong together. Social factors, early childhood experience, psychological, biological, and genetic factors, all collapse into a uniform analysis of the one condition. Social factors and experience immediately become psychological and biological factors on the level of the brain, and these factors can have a direct impact on the level of gene expression. This is even more profound when the brain is still developing during the formative years, when certain kinds of abuse can result in neurological developmental errors.

 

In early 1990, Hare and his team devised what became the psychopathy checklist, revised.[iii] This built upon earlier research that resulted in the psychopathy checklist,[iv] and has become the gold standard for diagnosing psychopathy. The list is composed of two sets of behavior, dividing them into antisocial traits and personality traits. This diagnostic tool generates a total possible score out of forty, and after a mental health professional has assessed the behavioral history of an individual, any score given in the high twenties and over thirty is indicative of a psychopath. Using this tool, many neuroscientists have created experimental groups of psychopathic individuals and have found unique brain differences between the psychopathic and the non-psychopathic. And so, despite ‘psychopath’ being a vague and somewhat empty term in Cleckley’s era, psychopath research today is incredibly rich from behavioral and neuroscientific input. This richness, coupled with the collapse of social factors in with the biological to describe the same condition, means that the term ‘sociopath’ should be extricated from discussions of the disorder.

 

The term ‘sociopathy’ does become useful again when considered in another context. Hare and Babiak described ‘sociopathy’ in their book, Snakes in Suits, thusly:

 

Sociopathy is not a formal psychiatric condition. It refers to patterns of attitudes and behaviors that are considered antisocial by society at large, but are seen as normal and necessary by the subculture or social environment in which they developed. Sociopaths may have a well-developed conscience and a normal capacity for empathy, guilt, and loyalty, but their sense of right and wrong is based upon the norms and the expectations of their subculture or group.

Hare & P. Babiak, Snakes in Suits[v]

 

This definition is really what sets the two terms apart. Psychopathy is understood as a mental disorder and has formal diagnostic criteria; sociopathy does not. Sociopaths have empathy, guilt, and remorse; psychopaths do not. It is this latter point that is the most profound, because neurological studies have shown us that the areas in the brain that are heavily implicated in moral decision-making are typically malformed and mal-developed in the psychopath. This means that the brain of the psychopath, physically and neurologically, will be significantly different from the brain of the sociopath.

 

With this new definition, sociopathy becomes so much more useful to us. We can now ask questions such as ‘How can someone commit devastating and destructive crimes if they have a conscience?’ and ‘If a sense of right and wrong is represented in a person’s personal ideology, what power do ideas have in influencing a person to commit crimes?’. Sociopathy presents us with the opportunity to study how those with a conscience can, at least temporarily, act unconscionably. It presents us with the opportunity to explore how those with strong moral codes can promote group solidarity, while treating those not in the group as subhuman; think gangs, or the Mafia, or paramilitaries. Exploring the ideas present in the manifestos of spree killers and hate groups also becomes relevant, as they usually purport a version of history where one or more groups in society present as a threat, and why action needs to be taken against this group. All of these people have a conscience, but over time it appears to have become punctured or torn. Sociopathy could help us to understand why this has happened.

 

If we explore perhaps the most antisocial of behaviors, taking the life of another, sociopathy as a study of the ideas that led up to the act adds to our wealth of knowledge of those with disorders or illnesses that can lead to murder. Not all psychopaths are killers, but it is easy to understand how they can kill. Not having a conscience and not feeling guilt or remorse, perhaps even coupled with the pleasure derived from killing or severely injuring others, could easily lead to the act being carried out. Others have suffered psychotic breaks, often over a period of time, and aggression has escalated to the point of lives being taken; this has been true in some with schizophrenia and related conditions. Visual and auditory hallucinations can convince them of the need to act, and when this is coupled with paranoia, something that is often present in the schizophrenic, patients are often compelled to act in a manner they consider appropriate and necessary. Now, it is arguable that as a psychopath does not have a conscience, then they are simply unable to develop a complex ideology of right and wrong behavior; but we could find that sociopathy is comorbid with schizophrenia. Auditory hallucinations become part of the schizophrenic’s experience, and thus represent to them a truth about the world. If, like has been documented elsewhere, the auditory hallucinations are believed to be voices from the supernatural, instructing the person to act, the patient could work those instructions into everything else they believe about the world. A patient with a religious faith could easily believe they are receiving divine instructions to end the lives of people who are secretly evil, for example, demons posing as family members. Their hallucinations make their belief system very real to them, and the drive to act comes from a strong sense of rightness, bolstered by the belief that they are perhaps an avenging angel with a divine mission.

 

There are other abnormalities with neurological correlates that could facilitate taking the life of another. Crimes of passion are quite common, where an individual experiences a heightened sexual or stressful state and lost, only temporarily, a state of rationality. Extreme emotions can sometimes dampen the ability to reason and think clearly, with catastrophic consequences. These can often be exacerbated with those susceptible to anger management issues, or serious stress disorders. Sociopathy could also be present here; a homophobic father who catches his child engaged in a homosexual act could prompt a loss of control due to stress and result in extreme violence. The father would have no doubt been exposed to homophobic ideology before witnessing his child in a same sex relationship, and used the component ideas to justify to him what is true about the world. The perceived infraction from the father’s moral code results in the stress and the loss of control. For the most part, the father has a conscience, and loves his child, but his beliefs about the world seemed to couple with witnessing this act, and worked together with poor stress control to temporarily suspend his conscience.

 

Brain tumors, physical damage to neurological tissue, as well as alcohol and drug use, are also all linked to violent behavior. Here, too, an overarching ideology of what is right and wrong about the world, could work in synchronization with these biological changes to motivate destructive behavior, and the compulsion to act aggressively could even further justify the truth value of the overarching belief system; it has to be true (and thus, right), because why would the desire to act be so strong, otherwise? But does something have to be wrong biologically for toxic ideologies to take root and influence behavior? This is also a question that merits further research. Experiencing the world negatively, either because of something biological, or maybe just suffering from intense psychological hurt and pain, would be enough to make a person crave understanding. During this time they will be receptive to any ideas that seem to explain the negativity, and perhaps claim to provide an answer to end or cure the suffering. This wouldn’t explain all sociopathic behavior, but it would go a long way to understanding its onset.

 

Sociopathic behavior could result if over time, exposure to negative ideas helped to diminish empathy towards other people, and is perhaps demonstrated best by considering the lives of spree killers. Elliot Rodger, Seung-Hoi Cho, Dylan Roof, Anders Breivik, and Christopher Dorner all wrote lengthy manifestos, and some maintained websites and made Youtube videos detailing their grievances at great length. There are various mental illnesses and disorders that have been implicated in the lives of some of those individuals, but it is sometimes hard to substantiate if a diagnosis was made or not. Regardless of conditions or disorders, the manifestos represent a detailed view of the world, as seen by these individuals, including what is wrong with it, and usually what in their view has to happen to fix these societal ills, perhaps taking the form of retribution and revenge. Constructing a manifesto takes a lot of time, and is a significant personal investment for the author; they have taken the time to create a reflection of the world that is accurate to them, built up of the ideas that they think represent the truth and depict reality. The tremendous effort and planning that goes into the manifesto begs the question of what role the manifesto played in bringing them up to their final act. Was it to help them understand why they needed to do what they felt was necessary, thus allowing their conscience to at least temporarily bend to murderous inclinations? Did it help to commit these acts, knowing that people could use the manifesto to understand why it took place, even though they no doubt accepted they would not be alive to witness this ‘understanding’? Finally, if hypothetically they were unable to put a manifesto together, or they believed nobody would ever understand their actions, would their final act still have taken place?

 

There is also the question of how ideology and determining what is true about the world can change after the experience of psychotic episodes. If auditory hallucinations convince a patient of imminent threats or inevitable actions, what the patient believes is true about the world could change; ideas that promote certain kinds of behavior are adopted to achieve goals that fit into an evolving ideological framework. When the psychotic episode has subsided, does the imminence and immediacy of these ideas decrease? Are the ideas eventually discarded as an inaccurate representation of the world? Psychotic episodes are no doubt traumatic because they force the patient to reassess how they are seeing and understanding the world around them, and the more they are forced to reassess, the more traumatic the experience. After a string of psychotic episodes, the patient could well still harbor ideas that became prominent during the last episode, and so certain inclinations that become mandatory are eventually expected. The entanglement of psychosis with ideas and conceptual representations of the world is clearly a crucial study, and could well illuminate the state of the patient’s conscience.

 

This study of sociopathy would also apply to soldiers, who have to be prepared to kill, and destroy infrastructure that could decrease the standing of living for civilians. Soldiers are trained to incapacitate or take the lives of enemy combatants, often by a bloody and violent means. For a soldier to be able to take this action, they have to at the very least temporarily suspend empathy towards other human life, and be comfortable after the carnage with the actions that were taken. Soldiers obviously go into the military with a conscience and do not join out of a love or desire to kill (there is certainly screening to catch this disposition). Ideology can assist with coming to terms with needing to kill, particularly those of nationalism and patriotism; believing that some war is unfortunate but necessary, the war was just, evil has been prevented, and the enemy is a direct threat upon one’s way of life (which is right and true).  When these ideas fail to resonate as true, perhaps based upon personal experiences, the life of soldiers can become a living Hell, especially if they are also suffering from stress-related disorders brought on by extended periods of combat.

 

If we take sociopathy to mean the use of ideology to at least temporarily suspend the conscience or diminish empathy towards others, the example of soldiers as sociopaths opens up an interesting dimension to the discussion. Regardless of political inclinations or personal worldviews, most people would reluctantly accept that sometimes it is necessary for soldiers to kill. Sometimes people have to kill other people. Most of us are fortunate in that we have people who do it in our stead, and we trust them to make those decisions and take all the necessary precautions to keep it as ethical as it can be. If one of the primary purposes of the soldier is to be prepared to kill, then within this framework of sociopathy, we condone the training of sociopaths to carry out this necessary and deadly behavior.  Here, it is crucial to keep this framework of sociopathy in mind, and not treat it as a synonym for psychopathy. Soldiers are not psychopaths. It would be a worthwhile study to track soldiers’ ideologies throughout their careers in the military, because exposure to extreme combat is likely to force the soldier to reassess how they see the world, in a similar manner to schizophrenics experiencing psychotic episodes (a severely agitated mental state, prompting a new understanding of reality). Any time that reality is re-assessed, values of right and wrong can be re-considered, and this will reflect in the overall conscience of the individual. Those forced to re-evaluate the world, due to agitation or trauma, will become open to new ideas and vulnerable to toxic ones, which is one of the reasons why these individuals need constant help and attention.

 

Connecting the dots between ideology and conscience is clearly of paramount importance if we hope to understand violence. This goal can be met with an open, honest, and concerted effort to study sociopathy on the level of the brain, the individual, and society.

© Jack Pemment, 2016

 

References

[i] Cleckley, H., The Mask of Sanity (3rd Edition), EPBM, Brattleboro (2015), p. 27

[ii] Hare, R. D., Without Conscience, Guilford, New York (1999), pp. 23-24

[iii] Hare, Robert D., Timothy J. Harpur, A. Ralph Hakstian, Adelle E. Forth, Stephen D. Hart, and Joseph P. Newman. “The revised Psychopathy Checklist: Reliability and factor structure.” Psychological Assessment: A Journal of Consulting and Clinical Psychology 2, no. 3 (1990): 338

[iv] Harpur, Timothy J., A. Ralph Hakstian, and Robert D. Hare. “Factor structure of the Psychopathy Checklist.” Journal of consulting and clinical psychology 56, no. 5 (1988): 741

[v] Hare, R. D.; Babiak, P., Snakes in Suits, Harper, New York (2007), p. 19

Hervey Cleckley Quotes #6

I am not sure there was ever much more need for “psychosis with psychopathic personality” than for “psychosis with red hair” or “neurosis with a Ph.D. degree.” The new nomenclature appears better designed to avoid unnecessary confusions of this sort.

Mask of Sanity

Elyn Saks: A tale of mental illness

I just wanted to share this video from TED Talks. It’s the remarkable personal account of Elyn Saks, a lady who suffers chronic schizophrenia – and has managed to live the life of a college professor and maintain a strong marriage. Her account of mechanical restraints during  hospitalization is harrowing.

“If you hear nothing else today, please hear this. There are not schizophrenics. There are people with schizophrenia. And these people may be your spouse, may be your child, they may be your neighbor, they may be your friend, they may be your co-worker.” – Elyn Saks

Recent crime and the need for mental healthcare reform

Alexis Carey Lanza

Aaron Alexis (left), Miriam Carey (center), Adam Lanza (right)

After a string of violent incidents that clearly indicate the presence of an unhealthy mental state, it is still shocking that a Congressional debate on improving mental healthcare in this nation has not been mentioned. Clearly, with the government shutdown, hands are probably tied right now, but it is not even getting suggested. Stop me if you have evidence of impending mental healthcare reform with the inclusion of ongoing care and assistance of the mentally ill once they have left hospital.

When yet another violent attack by an individual happens, everyone gets bogged down in motives and intentions, which are important, but secondary to the mental health of the individual. Poor mental health can only serve to exacerbate or create dangerous motives and intentions, and a discussion of the motives and intentions of mentally ill people cannot happen if mental health is excluded.

Human-Egg-Hatching

Mentally ill people hatching from their egg in the forest

These violent events often re-ignite quarrels about gun control. Regardless of whether or not you think all law-abiding U.S. citizens are entitled to own a gun, I think we can all agree that a gun in the hand of a mentally ill person is a recipe for disaster. What I think many fail to understand is that mental illness is not necessarily something you are born with and it can manifest itself at any point during a person’s life. It’s perfectly possible for a gun owner, who has safely owned and kept their gun for many years, to suffer mental illness. This does not automatically mean they will become a killer, but owning a gun might not be a good idea for this person any longer. Currently, in light of gun debates and commentary on mass shootings, the mentally ill seem to be treated like they are those ‘other’ people who hatch from eggs in the forest, and have nothing to do with us normal people.

Mental health is often excluded from initial discussions of these events, because as a nation we want immediate accountability. To say that a shooter killed a number of people was a schizophrenic who was off their medication is not a satisfying answer – it almost makes the event kind of pointless, meaning that lives were lost for nothing. To say that a killer was evil, had a hatred for a certain group of people, or was deranged as I’ve heard it explained, seems to give our rage and indignation of the event a focus or a purpose – after all, after a tragedy we need to stick our blame to something if we are to help our feet back to the ground.

Wanting to attach accountability to Aaron Alexis, the shooter at the Naval Yard in DC, in my opinion, is the easy and natural thing to do, especially for the victims and the victims’ families. But politicians and elected officials cannot allow themselves to fall back on this. President Obama referred to the intentions of Alexis as ‘cowardly’. This kind of comment is of no use to anyone – how is it useful to discuss the behavior of a man suffering psychotic symptoms, who had a shotgun in his possession and who killed 12 people, as acting cowardly? This attitude means that nothing gets done, and we’re almost guaranteed that a similar event is going to happen again. If the reason for a shooting is that the shooter was a schizophrenic off their medication, we should turn our indignation towards an inadequate mental healthcare system, and the absence of mental health education. We should also demand to know why so many red flags are often missed. Aaron Alexis had a ten year history of mental illness, was involved in three crimes, and yet he was still able to buy a gun and get a pass to work at the navy yard – this is the failure, and this should be the target of our national indignation.

In light of the shooting at the navy yard, a number of pundits were also quick to jump on Obama’s comment that if he had a son he would look like Trayvon Martin, and quipped, “If Obama had a son, he would look like Aaron Alexis.” This is no doubt supposed to be humorous because a number of conservatives and Zimmerman supporters were irked by Obama’s comment about Martin, because in their opinion Martin had been a threat. Alexis was a threat, and this is not something that is divided by opinion. Therefore, this recent comment serves to ridicule Obama’s original statement about Martin. This snide attempt to ridicule Obama is appalling, because it serves to undermine Alexis and his history of mental illness. Alexis “could’ve” been Obama’s son, because even people with schizophrenia have parents, and threat or not, Martin is now dead, after having only a very brief life. This kind of commentary only serves to obfuscate the real issues.

Whenever these type of tragedies come to pass, as they do all too frequently, there’s always mental illness or a mental disorder. Miriam Carey, the lady recently shot by police for driving her car into security barriers in DC, had suffered post-partum depression and psychosis. Adam Lanza, the teenager responsible for the Sandy Hook tragedy was diagnosed with Asperger’s and Sensory Integration Disorder (SID), and also had many articles about Anders Breivik, the Norwegian mass killer who shot dead many people, including children, on the island of Utoya  in 2011. Figuring out how the disorder could have resulted in these acts is not always straight forward, but poor mental health is always there. Even with pathological serial killers, the brain is different from everybody else. In fact, I’m going to go out on a limb and say that anytime a person’s natural in-built capacity for empathy fails completely, there is probably a disorder or the potential for a disorder present. This does not necessarily mean that an act of violence will result, but the chances have certainly increased.

One last thing I would like to comment upon is the term ‘isolated event’. Often after a mass shooting or an event that included the dangerous behavior of a citizen, you often see police officials or the media saying that it was an isolated event. I think this serves at least two purposes. Firstly, it lets us know that it wasn’t the result of terrorism, and there aren’t going to be similar acts to follow. And secondly, it bolsters the idea that the person responsible has been neutralized and will not commit further atrocities. I would like to contend that none of these events are isolated. They may not be the result of terrorism, but the issue of mental illness is behind all of them. Together, these events suggest that there is a tremendous ignorance and ineptitude regarding the mentally ill, and as mental illness can impact any of us at any time (either personally or by the actions of others), we need to stop looking at it as some weird anomaly that happens to other people, and start treating it as a human, national problem.