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edited by Theodore Millon, Ph.D., D.Sc., Erik Simonsen, M.D., Morten Birket-Smith, M.D., and Roger D. Davis, Ph.D.; New York City, Guilford Press, 1998, 476 pages, $60
This book is essential reading for any clinician, jurist, or criminologist who will encounter, diagnose, manage, or treat a psychopath. Given both the rise of incarceration in the United States and the increasing interest in civil commitment for sexual predators, many of whom have psychopathy as a comorbid diagnosis, this book is a must. The cast of writers is international and outstanding.
The book is divided into five parts, on history and viewpoints, typologies, etiology, comorbidity, and treatment. In most of the 28 chapters, the authors give their definition of the psychopath for reference within their chapter. These definitions create a sense of redundancy, but given the controversy that has surrounded the diagnosis of psychopathy—even though it is allegedly the "best validated clinical construct in the realm of psychopathology"—the definitions do provide needed clarity.
The definition provided by Robert Hare in chapter 12 appears to be comprehensive and congruent with others: "Psychopathy is a socially devastating disorder defined by a constellation of affective, interpersonal, and behavioral characteristics including egocentricity, impulsivity, irresponsibility, shallow emotions, lack of empathy, guilt, or remorse, pathological lying, manipulativeness, and the persistent violation of social norms and expectations." The definition helps us understand immediately what Cleckley (1) wrote about so clearly in The Mask of Sanity: that this diagnosis has a number of defining attributes that have been part of its mystery and are still part of its uncertainty.
Historically, DSM-II, DSM-III, and DSM-III-R identified this personality disorder by the use of descriptors. However, the term "psychopath" fell by the wayside in DSM-III in 1980, and the diagnosis of antisocial personality disorder arose in its place. In DSM-IV seven items were listed as defining adult antisocial personality disorder. They were substantially condensed and simplified from those in DSM-III-R, but they were not clinically tested, and they were not validated. Therefore, we have no idea how reliable or valid the current seven-item set is. In the continuum of psychopathy to sociopathy to antisocial personality disorder, the impact of the innate personality disorder shifts from a focus on intrapsychic dynamics to rule breaking and the social cost.
Thus Hare's Psychopathic Checklist—Revised (PCL-R) has come to be the gold standard for making the diagnosis of psychopathy, both in the general population and in prison settings. Because this assessment tool is so important, a brief description of it is warranted. The PCL-R is a 20-item checklist—or, more accurately, a 20-item clinical-construct rating scale—completed on the basis of a semistructured interview and detailed collaboration or file information. Each item is scored as 0, 1, or 2, yielding a maximum possible score of 40. The mean PCL-R scores in North American populations of male and female offenders typically range from 22 to 24, with standard deviations of 6 to 8. Mean scores in North American forensic psychiatric populations are somewhat lower, around 20. For research purposes, a score of 30 is generally considered indicative of psychopathy. The PCL-R now has a shortened version, called the Psychopathic Checklist: Screening Version, that also appears to be valid and reliable in identifying this disorder.
Those who have challenged and checked the internal consistency of the initial Psychopathic Checklist and the later PCL-R have found that the checklist measures a unitary construct that consistently reveals a stable, two-factor structure. Factor 1 consists of items having to do with the affective interpersonal features of psychopathy, such as egocentricity, manipulativeness, and callousness. Factor 2 reflects features of psychopathology associated with an impulsive, antisocial, and unreliable lifestyle or social deviance. In fact, these two factors are guidelines to the polarity of this personality construct. Factor 1 reflects its innate pathology, which later in the book Otto Kernberg describes as part of the intrapsychic dynamic formulation. Factor 2 describes the impact of the personality in terms of rule breaking, which becomes better associated with the personality-trait literature. Some authors do not believe that psychopathy is a valid construct; however, the book, in my opinion, convincingly presents research that shows that it is valid.
While the second part of the book describes different types of psychopathy, the fourth section, on comorbidity, describes the relationship of psychopathy to schizophrenia, somatization disorders, mood disorders, suicide attempts and suicide, anxiety disorders, other personality disorders, and substance abuse. The chapter by Darwin Dorr focuses on the relationship of psychopathy to pedophilia. Psychopathy as it relates to alcoholism and polysubstance abuse is given a separate chapter, as is the attempt to differentiate psychopathy from the sadist personality in murderers. Each of these chapters is filled with reports of current studies that cogently define the relationship of psychopathy to the specific topic area, with the overwhelming bottom line that psychopaths are at great risk for experiencing comorbid symptoms.
The section on treatment, which starts with chapter 23, may be the most useful and yet the most distressing. With the current state of the art of psychopharmacology, drugs that have an impact on irritability, preaggressive feelings, and impulsivity, especially the selective serotonin reuptake inhibitors (SSRIs), are beginning to show promise. Controlled studies indicate that SSRIs help some psychopaths gain control over emotions like impulsivity and anger that disrupt life.
Kernberg's chapter on the psychotherapeutic management of psychopathic, narcissistic, and paranoid transference is must reading for therapists. The feelings that psychopaths generate in those around them, including therapists, can be quite devastating. Furthermore, psychopaths can generate these feelings in themselves by identifying with the feelings they generate in others. In describing the effects of treatment, Kernberg states, "I believe that the prognosis in the work with such patients depends, in part, on the structural characteristics of their illness and, in part, on developments that can be assessed only during the treatment itself." He is still optimistic that change is possible, but outlines specific guidelines that the therapist must use when approaching such a patient.
A group therapy model and a therapeutic community model are both rated as promising treatment modalities when they are properly designed—that is, when they are structured to include healthy decision makers in the decision-making tree. In another chapter Jeremy Coid addresses the management of dangerous psychopaths in prison. He points out that 75 percent of inmates in English and American prisons qualify for a DSM-IV diagnosis of antisocial personality disorder and that, based on the PCL-R, about one-third of those inmates, or 25 percent of the total, qualify as psychopaths. The super-maximum-security prison is now becoming a more standard administrative approach to contain and control recalcitrant and unchangeable psychopaths, who can be devastatingly destructive to the prison system and to individual inmates.
Psychopathy is both an easy and a hard book to read. Although the psychopath has been described in the Bible, in classical and medieval literature, and by Shakespeare, it was not until Cleckley (1) wrote The Mask of Sanity in 1941 that we came to realize that pathopathy is a personality disorder that wreaks havoc on personal and societal institutions. As reported in chapter 8, Westman estimates that each sociopath costs society about $50,000 a year.
Whether psychopathy is a product of genetics, neurobiology, or childrearing practices or whether it represents a moral defect in character or is an expression of "evil," we must agree with William Reid, who states in chapter 7, with more passion than science, that for the greater good of society, "We must stop identifying with the chronic criminal and stop allowing him to manipulate our misplaced guilt about treating him as he is: qualitatively 'different' from the rest of us." Amen.
Dr. Maier is a psychiatrist in the forensic program at Mendota Mental Health Institute in Madison, Wisconsin, and clinical associate professor of psychiatry at the University of Wisconsin-Madison.
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