What is the distinction between Anti-Social Personality Disorder and Psychopathy? Is this distinction practically useful?
The first step in answering such a question would be to define the terms, it is here that the first problem is encountered. On consulting Rycroft (1977, p.12) it appears that “behaviour disorder is a psychiatric diagnostic term embracing psychopathy…” This definition paraphrases that contained in the fourth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders referred to by Hare(1993 p.24). In addition to being enduring patterns of markedly deviant behaviour, the characteristics are first diagnosed as a disorder in adolescence or early adulthood. The American definition judges anti social behaviour disorder by what is done. A vastly different definition can be found in Home Office Research Document 225 (Moran & Hagell 2001), where, what is put forward, is acceptable behaviour, once again, specifically in adolescents. Thus the Home Office/NHS definition of anti social behaviour is one in which adolescents fail to meet the set of criteria that would identify them as functioning normally. They are judged by what they fail to do. In this document Moran and Hagell do go on to define anti-social personality disorder as an extreme form of anti-social behaviour. They also make a very important distinction, “anti-social behaviour is what people do whilst anti-social personality disorder is what people have.
Psychopathy is a psychiatric and medico legal term for what used to be called moral imbecility. Despite the fact that Cleckley (1952) suggests that the term psychopathic personality was replaced by personality disorder, it was still in use by the medico-legal authorities in England and Wales as evidenced by its use in the Mental Health Act 1959 where it was defined as:
“a persistent disorder or disability of mind (whether or not including sub normality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatment”
In common with anti-social personality disorder, psychopathy is something that a person has rather than does. This distinction from other deviant or socially unacceptable behaviour allows for the treatment of offenders in special hospitals.
If these definitions are not sufficient to confuse, in the United States of America the terms psychopath and socio path are used interchangeably. Hare (1993 pp 23-24) condemns this practice and contrary to a large body of medical opinion posits that the terms anti-social personality disorder and psychopathy are not interchangeable either. Hare (1993 p.22) suggests that the confusion and uncertainty surrounding the term psychopathy for which he claims a literal meaning of “mental illness” is largely due to inappropriate and irresponsible use of the term by the media. According to Hare,(1993 pp34-70) the difference between anti-social personality disorder and psychopathy is that the former refers primarily to a cluster of criminal and antisocial behaviours whilst the latter is a syndrome defined by a cluster of both personality traits and socially deviant behaviours. He has produced a list of key symptoms of psychopathy.
Hare shows that the criteria for diagnosis of psychopathy is, or should be, different, and following on from this, it can be seen that whilst most criminals are not psychopaths many criminals will have some degree of anti-social personality disorder. If the distinction between psychopathy and anti social personality disorder was universally agreed and referred to in the treatment of offenders then it might have a practical usefulness. Alas this is not the case, even the criteria for determining psychopathy cannot be agreed. In 1995 Prins as quoted by Bartlett and Sandland (2003 p311) added further indicators to the criteria for diagnosis. Does this mean that some offenders have previously been misdiagnosed?
The distinction that Hare continues to make between psychopathy and anti-social behaviour is not universally accepted. In England, the medical profession are slowly beginning to contest the insistence of separating psychopathy from anti-social personality disorders. Bartlett and Sandland (2000 pp48-51) point to the fact that Section 1(2) of the Mental Health Act 1983 defines the terms used in the Act and whilst they accept the definition of other terms in the sub section they strongly contest the validity of the definition of psychopathic disorder. They base their argument on the fact that the criteria for definition are not distinct from the results of that behaviour. They argue that:
“abnormally aggressive or seriously irresponsible conduct does not merely characterise the malady; they are indistinguishable from it, at least in current medical understanding”.
They suggest that the medical profession consider the term psychopathy outdated and prefer instead to speak of anti-social or dis-social personality disorder. It is not only within England and Wales that there is disagreement, the mental health legislation in Scotland and Northern Ireland does not distinguish between psychopathy and anti-social behaviour disorder. Even amongst the legal and medical establishments of Great Britain and Northern Ireland there is no agreement.
Gough (1968) suggests that the concept of psychopathy can be traced to the work of J. C. Pritchard who in 1885 classified psychiatric disorders into two broad categories, moral and intellectual sanity. Pritchard referred to aberrations of the conative and emotional areas of the brain. That Pritchard’s thinking affected other health professionals can be inferred from the work of Grob (1994 pp149-150) in which he recounts the history of Boston Psychopathic Hospital which opened
in 1912. Amongst the variety of deviant types who were treated there, were prostitutes and juvenile delinquents. By current definitions these types indulge in anti-social behaviour but without further in-depth diagnosis neither would be classed as psychopathic.
Perhaps this type of thinking was influenced by Ceasare Lombroso (1876) who claimed that the heavy punishments of his day could not be justified by the effect they might have, because the behaviour of those who committed crime could not be changed. They were born criminals.
In an age of more enlightened approach towards criminality Fennell and Yeates (1999) propose that there is undoubtedly a moral hierarchy of mental disorder. They suggest that in crude terms the mentally ill are divided into ‘afflicted or deserving mad’ whilst people with anti social personality disorder; and the definition which includes psychopathy is assumed here; are seen as the bad mad or undeserving mad. Unfortunately it seems that this classification of the mentally ill, fuelled by the media has developed a strong and negative influence on popular perceptions of those mental disorders which are identified by anti-social behaviour.
The theory of criminal behaviour proposed by Eysenck in 1964 muddies the water even further Peck and Whitlow(1979) examine his claims that extroverts are more likely to show more criminal behaviour. Although a later study by Cochrane in 1974 discredited this conclusion it does point to an over emphasis on which type of people are prone to anti-social behaviour rather than why anti-social behaviour occurs.
At least Hare (1993) makes an attempt to explain why psychopathy occurs in certain individuals, he suggests that something is missing and that this something is conscience. A dictionary definition of conscience would include, moral sense, the sense of right and wrong. It is this sense which is missing in the psychopath. In psychology the notion of conscience is closely related to the psychoanalytic theories of Freud. Wrightsman (1997) explains how these theories have contributed to social psychology and particularly the understanding of the socialisation of the individual. He explains that the contents of the superego are distilled from the influences of parents, teachers and other persons and eventually become internalised as conscience.
Braithwaite (2003 p394-395) in his work on re-integrative shaming suggests that conscience is what prevents most people from committing crime rather than the deterrence of punishment. He suggests that societies which replace much of punishment, as a means of social control, with shaming and appeals to the better natures of people, have less crime. The argument continues that punishment should be reserved for the psychopaths because they are beyond shaming. The problem arises once again that punishment will not deter further offending. The psychopath will play the game whilst confined but on release, because of his inability to learn from experience, will continue to offend. Braithwaite’s suggestion indicates that our prisons should be
full of psychopaths which is clearly not the case. If this argument was put forward in respect of people suffering from anti-social personality disorder it would be more credible.
The notion of born criminal continues and to compound the problem further Graft (1961) suggested that there is probably more than one type of psychopath, he included, brain damaged, affectionless, emotionally unstable and impulsive. To this list can be added the sexual psychopath (Dobson 1981). Without actually using this phrase Marshall and Barbaree (1990) as cited by Ward, Polaschek and Beech ( 2006 pp33-45) suggest similarities between psychopaths and sexual offenders, notably that both groups are likely to have experienced physical and sexual abuse as children. Although there may be some similarities between types, not all sexual offenders are psychopaths, nor are all psychopaths sexual offenders. Such indiscriminate use of the term psychopath is not helpful and probably only serves to fuel the belief that nothing can be done to alleviate the condition. As late as 1976 Cleckley, whose work is discussed by Hare(1993 pp27-28) suggested that since psychopaths cannot benefit from experience there is little that can be done for them.
Perhaps this pessimistic view stems from the belief that the onset of anti social personality disorder occurs in adolescence or early adulthood. Hare (1999) cites the work of sociologist William McCord in which it was concluded that although attempts to deflect a person from psychopathic patterns in early life had not been successful, there was hope for those programmes in which an individual’s social and physical environment was completely changed. McCord appears to have recognised that sufferers from anti-social behaviour disorder are not born bad but might be made bad as a result of early life experiences.
This suggestion appears to be born out by the work of Rutter et al (2007) with Romanian adoptees who had suffered trauma as a result of institutional deprivation. Rutter and his colleagues have shown that the early influences in life, particularly the influence or lack of parental care, can have profound effects on the development of the child. It is not suggested that early separation from the mother automatically causes anti-social behaviour disorder, but Rutter and his colleagues have shown that adverse early life experiences do cause trauma and disruption of emotional and psychological development, what has been described as the primal wound. What is important about studies of adopted institutionalised children is that whilst their behaviour is what they do, it can be linked to the trauma they have suffered and to the resultant emotional and psychological problems that they have.
Optimistically Rutter believes that even when emotional and socialising deprivation has occurred, it can be addressed, and the sooner it is addressed, the greater the chances of the abandoned child leading a relatively normal life. He found that those children who had been
institutionalised for less than six months fared better than those who had been institutionalised for a longer period. Rutter and his colleagues discovered that children in their sample who had suffered institutional deprivation in Romania had greater problems than those from Romania who had not been in an institution, or children who had been adopted from within the U.K. It was noted that IQ and inattention had a negative effect on scholastic attainment, the children exhibited autistic like patterns, possibly a response to profound lack of interpersonal interactions and conversations. These children also suffered dis-inhibited attachment, inattention/over-activity problems and emotional and conduct disturbances. The findings concerning scholastic attainment are borne out by research conducted by Beckett et al (2007).
When considering the work of Goldfarb (1943) as cited by Woods (2004) the foregoing should not be surprising, his research showed that institutionalised children show higher levels of aggressive behaviour and score lower in IQ and sociability tests than non institutionalised children but these problems were more severe for those children who remained in the orphanage for longer.
A few years later Bowlby’s (1951) maternal deprivation hypothesis suggested that a failed or damaged attachment was likely to cause long term difficulties for a child. Despite the fact that Bowlby’s research was criticised as being flawed, Woods (2004) reveals that his emphasis on bonding and attachment has been held to be correct by Michael Rutter(1982)
If the foregoing is examined in the light of the NHS/Health Advisory Service indicators of 1995, that is;
a capacity to enter into and sustain mutually satisfying personal relationships,
continuing progression of psychological development,
an ability to play and learn so that attainments are appropriate for age and intellectual level,
a developing moral sense of right and wrong,
and a degree of psychological distress and maladaptive behaviour being within the normal limits for the child’s age and context,
it could be argued that unless these problems are resolved such children might be in danger of exhibiting anti-social behaviour and/or developing anti-social personality disorder.
This hypothesis is stated to make the point that a lack of clear definition, and aetiology in the study and management of anti-social behaviour disorder and psychopathy, if indeed the two are separate, only serves to encourage much more speculative explanations of behaviour. There is perhaps a belief that it is unreasonable to label a child as a psychopath and if this is one of the reasons that the British medical establishment prefer the designation anti-social personality disorder then this is beneficial, particularly if it prompts recognition that symptoms of the disorder are recognisable at a very early age. Certainly the research of Goldfarb, Bowlby, Rutter and others has shown that causes for anti-social behaviour in children can be identified and responded to, the earlier the response the greater the chance of effecting fundamental change.
Experimental data concerning the effects on animals of enriched and impoverished environments is readily available and supports the conclusions based on observations of adopted children. Boddy (1981pp205-208 ) describes experiments carried out by Bennet et al in 1964 in which it was found that rats from age twenty five days to eighty days reared in an enriched environment had cerebral cortices which were thicker and heavier than rats of the same age reared in impoverished environments. This study was complemented by work conducted by Krech et al in 1962. This study found that differences in learning ability correlated with structural and biochemical differences induced in the cerebral cortex as a result of exposure to different environments. Obviously similar experimentation on the human brain is unacceptable and the only evidence available is from the post mortem examination of human brains. Boddy points to the study of the brain of a blind deaf mute carried out by Donaldson (1980) which was found to have atrophied visual and auditory areas. Sight and sound were missing as a result of defects in the corresponding areas of the brain. If, as the studies with institutionalised children appear to show early damage due to a deprived environment may be repairable, why does there appear to be permanence of psychopathy or anti-social behaviour disorder in adults?
The psychopathic personality scores high as an extrovert and Boddy (1981 p253) quotes Gray’s work of 1972 in pointing out that the extrovert is not readily conditionable because the septo-hippocampal system which inhibits responses that have been punished or have failed to elicit reward is relatively insensitive. There is more than a suggestion here that conscience, guilt and remorse are missing in the psychopathic personality because of a defect in the septo-hippocampal system. Because of their psychological profile psychopaths and people suffering from anti-social behaviour disorder are unlikely to seek out or even believe that they need therapy. If this class of person is forced into undergoing therapy, for example by the justice system, they are unlikely to take an active part in their treatment. It could be argued that their belief systems are so entrenched that they cannot be changed.
Aitkenhead and Slack (1985 p323) suggest that we acquire a large body of knowledge over a lifetime and that this knowledge is incorporated into our belief systems which then affects our interactions with society. It maybe that certain information has to be acquired at specific times in life. Body (1981 p208) points to the work of the ethologist Nash in 1970 which has wide support amongst psychologists. Nash suggested that the external stimuli for many crucial events in development must occur within critical periods. If this is true then it would explain why adults with psychopathic personality disorder or anti-social personality disorder do not, indeed cannot respond
to therapy. If the window of opportunity for essential socialising influences can be identified then steps can be taken to ensure the necessary conditions for socialisation are present. In the absence of this information an assumption that these conditions should be available from birth or as soon as possible afterwards may eliminate or reduce the instances of psychopathy and anti-social behaviour disorder.
There is no doubt that anti-social behaviour disorder and psychopathic personality disorder cause problems for society and for the individuals concerned. Even here there is no clear understanding of the immensity of the problem. Rutter, Gillo and Hagell (1998) suggest that obtaining accurate data on which to assess the state of the problem that anti -social behaviour poses is also problematical. There is no single source of data concerning anti-social behaviour, therefore data has to be drawn from official statistics, criminal records, victim surveys and self report data which means that research is based on estimates rather than facts.
What is the distinction between Anti-Social Personality Disorder and Psychopathy? Is this distinction practically useful? It is difficult, if not impossible, to determine if there is any real distinction between these two afflictions or if there is only one malady with two or more names. Hare(1993 pp34-70) does make a distinction between anti-social personality disorder and psychopathy in that one refers primarily to a cluster of criminal and antisocial behaviours whilst the other is a syndrome defined by a cluster of both personality traits and socially deviant behaviours. Hare’s view seems to be in the minority. The continued distinction appears to have no practical use at all. Scotland and N.Ireland seem to manage quite well without making a legal distinction. A universal adoption of the term anti-social behaviour disorder or better still, psychopathy in its original meaning of “mental illness” might have more practical use if it removed the sad/bad madness dichotomy. More accurate collection of data would obviously help to obtain a clearer understanding of the extent of the problem. The practice of waiting until adolescence or early adulthood before diagnosis,when previous research indicates that at this point nothing can be done to change behaviour, seems to be insane. In the light of the work conducted by Nash, Goldfarb, Bowlby, Rutter and others, the sane, the moral, thing to do would be to diagnose as early as possible after birth and then put measures in place to ensure that all developmental milestones are achieved. What the affliction is called is not nearly as important as its treatment.
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