Psychopaths Among Us

As the number of mass shootings seems to be on the increase, many have wondered what types of people commit these acts. As I noted in my June 20, 2015 post,  some of those who are racially motivated may have Delusional Disorder. I noted in my May 31, 2014 post, some may have Narcissistic Personality Disorder and/or Bipolar Disorder perhaps exacerbated by the wrong type of medication. But the diagnosis most often correlated with violent behavior is Antisocial Personality Disorder, which is better known by its earlier terms, sociopathy and psychopathy. All three terms refer to the same condition.

It used to be believed that psychopathy (I'll use that term for this blog post) was a rare condition. It isn't a rare condition. Studies referenced in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-V) indicate the rate of Antisocial Personality Disorder, or psychopathy, is somewhere between .2 and 3.3 percent of the population.

It is commonly and inaccurately believed--including by some members of my profession--that psychopaths are found mostly in the criminal justice population. I used to work with people paroled from state prison, in the 1990s, and I have seen a rate of psychopathy in my private practice that is about the same as what I saw in my job with the parolees. Most of the parolees weren't arrested for crimes committed to gain psychopathic thrills; most were arrested for selling drugs or committing burglaries or robberies in order to support heroin addiction or crack cocaine addiction. Our prisons aren't overcrowded with psychopaths.

Psychopaths have come to my private practice for a variety of reasons including having been arrested, having committed a serious crime that did not result in arrest but resulted in interpersonal problems, and because of job problems, educational problems, addiction, and depression.

It is commonly believed that psychopathy is untreatable or barely treatable. Some therapists like to say that "the only reason psychopaths come to therapy is to learn how to be better psychopaths." Is this true?  The psychopathic persons who came to see me who were struggling with depression or early recovery from addiction definitely wanted help for those problems. I do believe that I helped them, but the underlying personality disorder remained more or less intact. The persons who came to treatment due to outside pressure were less treatable, but I do believe we were able to work on some issues when the patient was being honest with me. I only recall one psychopathic patient who I became convinced was simply making up stories, perhaps in order to get a thrill out of manipulating someone.

Psychopathy, or Anti-Social Personality Disorder, is usually characterized by difficulty following rules and social norms, deceitfulness, lack of empathy, impulsivity and aggression. It is thought to be more common among men, but I question that statistic, because half the psychopaths who have come to my private practice have been women. But perhaps female psychopaths are more likely to seek treatment.

The best treatment, as it is in many disorders, is prevention. The DSM-V notes "Adoption studies indicate that both genetic and environmental factors contribute to the risk of developing antisocial personality disorder." Past studies have correlated psychopathic behavior with childhood abuse and neglect and with inconsistent parenting (parents who disagree over rules or a parent whose discipline seems arbitrary). Ideologies that provide a rationale for violence help psychopaths commit violent acts. Societal alienation may exacerbate the characterological lack of empathy. Anyone who sees him or herself as having little to lose is more likely to commit a violent act that ends in his or her own death or arrest. This last factor indicates that depression may exacerbate psychopathic behavior, although I am unaware of any scientific research on this subject.

The DSM specifies that for antisocial personality disorder to be diagnosed, the person must have had some symptoms starting before age 15. Perhaps if we did better screening, referral and treatment of children and teens exhibiting psychopathic behaviors we would not see so many acts of mass violence. Treatment should include treatment for parents or other significant family members as well as parent training to teach appropriate discipline. In some cases, removal of the child from the home may be necessary, but because such removals are usually done long after the damage is done, and because foster and adoptive homes are also often not optimal, this may not result in prevention of violent acts.

Many factors contribute to psychopathic behavior. To prevent acts of mass violence, reasonable gun control laws should be combined with early intervention for children exhibiting serious conduct problems and lack of empathy for others.