Psychopathy versus sociopathy again…

I plan to review for you a very recent paper: Psychopathy as a disorder of the moral brain. Dr. Robert Hare is one of the authors. But, before I can get to explaining the moral brain part, I have to get past the first paragraph, so the moral brain will be have to be discussed more next week. As I sat down to translate this paper into plain English, I got stuck at the fourth sentence:

“Antisocial behavior by itself is a nonspecific symptom common to many conditions, so psychopathy and antisocial personality disorder (ASPD, American Psychiatric Association, 1994) are not analogous constructs while most cases of ASPD (sociopathy) do not fulfill the interpersonal and affective criteria for psychopathy (Hare, 2003; Ogloff, 2006) the behavioral features observed in these individuals are best explained by their level of psychopathy (Forth et al., 1996).”

O.K. let me get this straight, psychopathy and antisocial personality disorder are not the same thing so a sociopath is not a psychopath BUT to the extent that a sociopath is a sociopath, it is because he/she is a psychopath! Now, how are we supposed to understand that so we can start discussing the important point—the moral brain?

The first sentence of the paper sheds light on what the author is really trying to say, “Psychopathy is a personality disorder defined by a constellation of interpersonal, affective, and behavioral/lifestyle features, including manipulation and deception, grandiosity, shallow emotions, lack of empathy and remorse, an impulsive, irresponsible lifestyle, and the persistent violation of social norms and expectations.” What he should have said in the fourth sentence is that many people psychiatrists diagnose with sociopathy using the DSM do not score above 30 on the psychopathy inventory (PCL-R), so that by a strict definition they are not psychopaths. To give you some background about why there is an argument here please read Psychopath and Antisocial Personality Disorder: A Case of Diagnostic Confusion by Dr. Hare. He reports that the interpersonal behavior and emotions of psychopaths best define them. He objects to the fact that these are not emphasized enough in the current definition of ASPD, which places too much emphasis on antisocial behavior.

These arguments took place some time ago before it was discovered that both sociopathy (ASPD) and psychopathy are a spectrum. Before that time Dr. Hare said that “psychopaths” were those who scored more than 30 on his scale. But since that time we have discovered that many people who score between 20 and 30 on the tests have the same physical and brain abnormalities as those who score over 30. So in reality a person is not a sociopath or a psychopath a person simply possesses traits of these disorders to a high degree. The higher the degree of psychopathy the more likely it is that a person will have an abnormal moral brain. If we look at a group of people and do a correlation between the degree of sociopathy as measured by the DSM criteria and the degree of psychopathy as measured by the PCL-R there is a high correlation between the two. So your worst sociopath is also your worst psychopath. Rather than being an argument over trying to separate apples and oranges, this is an argument over how to best define an apple (or a bad apple depending on how you look at it).

Psychopathy and sociopathy are really patterns of extreme brain and endocrine function that we infer from observing a person’s behavior. The real question is which behaviors are most indicative of this extreme physiology? If you read the scientific literature you will discover that many individuals who score between 20 and 30 also have aberrant brain and hormonal function. So the problem is not criteria, the problem is the cut off score of 30 which is in my opinion too high. There are a couple of studies indicating people with scores as low as 12 might have abnormal moral brains. If the cut off for psychopathy is lowered to 20 or 25 there is considerably more overlap between the PCL-R and the DSM.

I happen to agree with Dr. Hare that his scale is better at identifying individuals high in psychopathic/sociopathic traits. But I don’t think he should stop at the PCL-R which is a test only specially trained clinicians can administer. He has also developed the P-Scan which is a 90 item test that anyone can use to rate another person’s psychopathy. I have used this scale and believe that if this was accepted as the rating scale for psychopathy/sociopathy everyone would be able to identify those high in these traits. Isn’t that what we should do? Why should the identification of morally insane people be only reserved for highly trained clinicians?

I also think we should get away from assuming sociopathy and psychopathy are categories that people either do or do not belong to. There are many instances where just a few psychopathic traits can do serious damage. Damaging people can have some of psychopathic traits and not others.

When psychopathic traits interact with a specific situation or opportunity to do harm there is likely to be trouble. An example of a trait-situation interaction is when a highly psychopathic person is a parent or spouse, or a boss. If the highly psychopathic person has low power and low situational opportunities for harm, he/she is less of a problem to society. Similarly society needs leaders and parents to be low in psychopathic traits because in these situations just a few traits bring out harmful behavior. If we focus on traits we can begin to discuss situation and trait interactions. If we focus on the traits, we will avoid making the mistake of saying, “He/she isn’t a sociopath, so he/she is O.K.” The authors are correct in saying that evil behavior is best predicted by the presence of psychopathic traits, irrespective of whether there is a “formal diagnosis” of psychopathy.

What I would like to see is studies of physiology using the P-Scan completed by relatives who know the subject well as an assessment. Although the question of what is different about the physiology of psychopaths/sociopaths is very important, it is not the only or even most practically important question. If psychopathy can only be identified by a few highly trained people, what good is the construct? But if we had a behavioral or psychological test that nearly anyone could use, and that test was related to abnormal physiology then it would be highly useful to humanity.

Furthermore, there are numerous hormonal and brain findings associated with psychopathy and sociopathy. It is likely that these findings relate to specific traits. For example, high testosterone is related to unrestricted sociosexual orientation, power motivation and impulsivity but is less related to low affection. In this regard, the P-Scan is very good because the 90 items examine psychopathic traits in detail. Next week, psychopathic traits and the moral brain.