A Duty To Differentially Diagnose

A Duty to Differentially Diagnose (Abridged Version)

(Abridged Version – 9 minute read)

          On January 11, 2020, exactly one month after individuals in the city of Wuhan had begun falling sick after going to a local food market, a team of scientists at the Shanghai Public Health 1Clinical Center led by YongZhen Zang, Ph.D., submitted gene sequencing data on an open platform hub for prepublication data designed to help public health activities. They had sequenced the genome of what came to be known as the COVID-19 virus and thus had definitively identified the pathogen causing the illness in Wuhan. The ability to define the pathogen set off the race among laboratories across the globe to halt the virus through the development of a vaccine and possible treatments. The knowledge those scientists shared on the infrastructure of the virus opened the door for efforts to hopefully defeat it.

            Sadly, the entire globe, but particularly the United States, is contending with another plague. The pathogen that set off this plague had been contained in right-wing fever swamps and tabloid celebrity hothouses, but leapt to the body politic in 2016 through a host who has been, unfortunately, a super spreader of the pathogen. Unlike COVID-19, this pathogen does not represent a new strain. It is a well-researched and well-understood condition called Psychopathic Personality Disorder (PPD). There is sufficient information about this condition to unlock its code. Hopefully, that shared knowledge and understanding can help curb the virulence of this second pathogen and mitigate the disaster that is unfolding because of it.

            Here is the sequence that unlocks the code:

            On January 11, 2020, exactly one month after individuals in the city of Wuhan had begun falling sick after going to a local food market, a team of scientists at the Shanghai Public Health 1Clinical Center led by YongZhen Zang, Ph.D., submitted gene sequencing data on an open platform hub for prepublication data designed to help public health activities. They had sequenced the genome of what came to be known as the COVID-19 virus and thus had definitively identified the pathogen causing the illness in Wuhan. The ability to define the pathogen set off the race among laboratories across the globe to halt the virus through the development of a vaccine and possible treatments. The knowledge those scientists shared on the infrastructure of the virus opened the door for efforts to hopefully defeat it.

            Sadly, the entire globe, but particularly the United States, is contending with another plague. The pathogen that set off this plague had been contained in right-wing fever swamps and tabloid celebrity hothouses, but leapt to the body politic in 2016 through a host who has been, unfortunately, a super spreader of the pathogen. Unlike COVID-19, this pathogen does not represent a new strain. It is a well-researched and well-understood condition called Psychopathic Personality Disorder (PPD). There is sufficient information about this condition to unlock its code. Hopefully, that shared knowledge and understanding can help curb the virulence of this second pathogen and mitigate the disaster that is unfolding because of it.

 

            Here is the sequence that unlocks the code:

I         There is a well-researched, strongly validated, consequential psychological condition called psychopathic personality disorder (PPD). The main feature of this disorder is a constellation of personality traits which inevitably result in significant harm to others from the person who has the disorder. The disorder has been carefully delineated and rests on a firm empirical foundation.

 

II          There is a high bar to meet diagnostic criteria for this condition (approximately 1% of the

            of the population does so). But if you do, there is a great deal we can say about you, and

            we can say it with a great deal of authority.

 

III        There is a strongly validated and reliable tool (the Hare Psychopathy Checklist) to diag- nose this condition.

 

IV        It is quite possible for a trained professional to undertake a diagnostic assessment of  the President ‘at a distance’ because of the voluminous data available on him. An inter view with the President is not needed, indeed may even be counterproductive (1)in the assessment of this particulardisorder, which is marked by deceitfulness and manipulat- ing others.      

 

V         There is ethical justification to conduct a thorough assessment of the President without his consent under either a ‘duty to warn’ or ‘duty to inform’ principle.                                  

              

VI        The President does meet diagnostic criteria for psychopathic personality disorder (PPD). Indeed, he falls in the moderate to severe range of this consequential condition.

 

VII       The implications of this diagnosis are serious and wide-ranging. The President, as well as all those in his sway, are, to a meaningful degree, at the mercy of this condition.

            His diagnosis allows us to predict, with a notable degree of precision, how he will con-                               duct the duties of his office.

Here are the details for each step of the above sequence.

I

                        There is a distinct condition called psychopathic personality disorder (PPD).

                        It is one of the best understood and  most thoroughly validated conditions

                        in the field of psychopathology. The essence of the disorder is a set of three

                        personality traits that inevitably result in harm inflicted upon others.

            The term psychopathy comes from the German word psychopastiche, which translates to ‘suffering soul’. In the early 19th century in Europe the term became affixed to that small group of individuals in society who are devoid of a moral sensibility; those who lie, cheat and steal with impunity. In the 1800’s and early 1900’s in America the term ‘moral insanity’ was often used to describe such individuals.

            Psychopaths appear to have been with us from antiquity through medieval times to the present. Descriptions from Greek and Roman mythology, the Bible, and classical literature are remarkably consistent in revealing the presence of those that were intellectually intact, but lacked the capacity for moral reasoning.

            No culture or station in life is immune from this condition. Psychopaths are found in pre-industrial societies (2), past and present, as well as in modern states. They are found among the the wealthy as well as the impoverished.

            The advent of modern psychiatry (3) — especially the establishment of reliability and validity in clinical diagnosis of disorders —  has enabled us to confirm the descriptions from classical literature: that there is a distinct clinical entity called psychopathic personality disorder (PPD) that is stable across history, culture and socioeconomic status. PPD is also stable across the lifespan of the individual who displays it. Psychopathic personality disorder is not just a term of disapprobation for (mostly) men behaving very badly, but a diagnosis that reflects a real world, clearly defined pathogen with predictable consequences.

            In order to appreciate this assertion, one first needs to understand what the term ‘personality disorder’ means in the world of modern psychiatry. Personality disorder refers to a limited number of conditions that are included in the two major diagnostic systems used throughout the world : The  Diagnostic and Statistical Manual of Mental Disorders Version Five (DSM-5) and The International Classification of Disease Version 11 (ICD-11). To qualify for a personality disorder, two conditions must be met:

            (1) The individual must display an enduring pattern (starting in childhood or adolescence and remaining relatively stable throughout the lifespan) of inner experience (thoughts and feelings) and behavior (impulse control and interpersonal relationships) that deviate markedly from the individual’s culture, and

            (2) The pattern is maladaptive and pathological. It causes distress (to self or others), dysfunction or disability.

            It turns out, that in the world of scientific investigation, there are a limited number of such extreme and maladaptive personality organizations.

            Psychopathy is one of them.

             But, because of its impressive empirical foundation, PPD should not be considered as just one of a limited number of these extreme and maladaptive personality organizations.

                         It is significant that a meeting of leading researchers on personality

                        disorders organized by the National Institute of Mental Health in

                        Washington D.C., in June 1992, concluded that the convergence of

                        biological, psychological and behavioral paradigms in the development

                        of theory and research on psychopathy was a useful model for the

                        construct validation of other personality disorders (4).

            There is an extensive body of clinical and research evidence (over 3300 studies) testifying to the validity of the construct of psychopathy(5). There is consensus from the scientific and professional literature over the past hundred years on the central, defining feature of the disorder: three symptom clusters or sets of traits that result in harm to others. These symptom clusters are seen in all subcultures. They are constant and immutable. They are not a “hoax”. They are not going to, “like a miracle, disappear.”

 

            Listed below are the three core traits that define this condition:

  1. Arrogant interpersonal style.

            This cluster of traits includes a relentless drive to dominate, hostility, grandiosity, sense of invulnerability, deceitfulness and antagonism.

 

  1. Deficient emotional experience.

            There are two facets to this cluster: the inability to bond with or have empathy for others, which leads to callousness; and the inability to experience shame, guilt or anxiety, which leads to remorselessness.

 

  1. Impulsive thinking and behavioral style

            Traits here include restlessness, difficulties in concentration, greater than normal need  for stimulation, inability to plan, deficits in perseverance, inability  to defer gratification, recklessness, and unreliability.

          If an individual meets diagnostic criteria for clinical psychopathy, it means he possesses the drive to dominate, remorselessness and impulsivity to an extreme and maladaptive degree. He is ruled by this trifecta of destructive tendencies. It is an affliction that inevitably leaves damage in its wake.

II

              There is a high bar to meet diagnostic criteria for this condition (approximately 1% of the of the population does so). But if you do, because of  the impressive  research conducted, there is a great deal we can say about you and we can say  it with a great deal of authority.

 

            For anyone suffering from psychopathic personality disorder, we can say:

            (1) The condition is, to a significant degree, inherited, rather than the result of a

            difficult upbringing or environment (6).

            (2) What is inherited?  An abnormal brain. Neuroscientists have found functional and structural  neurological abnormalities in psychopaths that can be reliably diagnosed  using functional magnetic resonance imaging (fMRI). These abnormalities are deficiencies in areas of the brain that help explain the three core traits of the  disorder (7).

            (3) The condition is stable. It surfaces in childhood and does not abate significantly

            over the lifespan.

            (4) The condition is immutable. There are no effective treatments for it.

 

            Understanding the strength and intractability of the  core traits of remorselessness, drive to dominate, and impulsivity that define his disorder, we are in a position to explain the President’s response so far to the pandemic and recent civil unrest; and how he will behave going forward.

III

           There is a strongly validated and reliable tool (the Hare Psychopathy Checklist) to  diagnose this condition.         

 

            Our ability to reliably diagnose psychopathy is largely due to the development of rating scales, the Hare Psychopathy Checklists, designed to measure the degree of psychopathy in an individual. The Checklists were designed by Robert Hare, a Canadian psychologist, and his colleagues. The Psychopathy Checklist – Revised (PCL-R) has 20 items and was developed  with a prison population in British Columbia. It is particularly recommended for assessment of individuals with a criminal history. The PCL:SV (screening or clinical version), which focuses on the interpersonal and affective symptoms of psychopathy, has 12 items and is recommended for individuals without a criminal history.

            Hare and his colleagues developed the checklists by listing over 100 behavioral, emotional, interpersonal and lifestyle traits that had been observed in criminal populations. They relied heavily on the work of Hervey Cleckley, considered the pioneer in the study of the “criminal mind” and author of Mask of Sanity in the 1930’s. In that book he detailed the psychopath’s often “brilliant and charming” manner, which masked a predatory nature and a lack of conscience. Through statistical analysis and studies to establish reliability and validity, Hare was able to winnow the original list of traits to 22 items, which he published in 1980, and then revised to 20 items in 1991. The clinical version (PCL:SV) with 12 items was published in 1995.

            Although much had been written about the psychopathic personality before, Hare and his colleagues established the first systematic effort to assess and study psychopathy. His psychopathy checklists became the gold standard, the common and objective measurement tool used to generate the research that is the foundation of our current knowledge. As a result, psychopathy has benefited from more attention and research than any other personality disorder. In addition to its solid psychometric qualities, the PCL-R and PCL-SV emphasize longstanding and stable behavioral and personality traits. The rating system for each checklist requires culling life history data that can identify chronic, persistent and entrenched traits (as opposed to flamboyant criminal behavior) that we now understand are at the heart of the condition.

            The checklists should only be administered by a qualified and trained professional. Administration is a two part process of analyzing life history data and conducting a semi-structured interview, after which the interviewer provides a rating for each item (0=no evidence of trait; 1=some evidence for trait; 2=trait definitely present). Hare wrote a book-length manual with extensive definitions and behavioral examples for each of the twenty traits in order to facilitate consistency and reliability of ratings.

            A “perfect” score (very rare) for psychopathic tendencies on the PCL-R would be 40. Hare set 30 to be the cutoff score for one to be deemed a clinical psychopath. A “perfect” score on the PCL:SV would be 24, with a cutoff score of 18 to place one solidly in the psychopathic range.

            Here are the 20 items from the PCL-R that the examiner is asked to provide a rating of 0, 1, or 2:

  1.  Glibness/superficial charm;
  2. Egocentricity/grandiose sense of self-worth;
  3. Proneness to boredom/low frustration tolerance;
  4. Pathological lying and deception/gaslighting;
  5. Conning/lack of sincerity;
  6. Lack of remorse or guilt;
  7. Lack of empathy/callous;
  8. Short-tempered/poor behavioral controls;
  9. Promiscuous sexual relations;
  10. Early behavior problems;
  11. Impulsivity;
  12. Juvenile delinquency history;
  13. Frequent marital relationships;
  14. Parasitic lifestyle;
  15. Failure to accept responsibility for own actions;
  16. More than one type of criminal offense;
  17. Lack of realistic long-term plans;
  18. Shallow affect/superficial emotional responsiveness;
  19. Poor probation or parole risk; and
  20. Cunning/manipulative

Here are the 12 items from the PCL:SV:

  1. Superficial/glib
  2. Grandiose/boastful
  3. Deceitful
  4. Lacks remorse
  5. Lacks empathy
  6. Doesn’t accept responsibility
  7. Impulsive
  8. Poor behavioral controls
  9. Lacks goals
  10. Irresponsible
  11. Adolescent antisocial behavior
  12. Adult antisocial behavior

            The reliability (different clinicians using the Hare Checklists come to the same diagnosis) and validity (the checklists are in fact assessing a distinct entity called psychopathy) of the checklists have solid psychometric support (8).

            Given Trump’s history of alleged criminal behavior, it seems appropriate to consider his score on both of these instruments.

            But can a mental health professional come up with a valid score on the Hare Psychopathy checklists without personally examining the President?

IV

                        An interview with the President is not necessary. There is

                        sufficient, high-quality informant and archival data available

                        on him to provide a thorough diagnostic assessment.

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            In order to justify assigning a diagnosis to the President ‘at a distance’, we need to address a guideline in the American Psychiatric Association’s code of ethics called the Goldwater Rule. The Goldwater Rule asserts that a mental health professional has to directly examine a public figure and secure consent from them before offering up a diagnosis.

            The Goldwater Rule was established because, during the 1964 Presidential campaign, FACT magazine (now defunct) invited psychiatrists to participate in a survey on the psychological makeup of candidate Senator Barry Goldwater. Psychiatrists that responded branded Goldwater with various diagnoses and descriptors, such as “paranoid,” “schizophrenic,” “psychotic,” and “narcissistic.” Most responders claimed Goldwater was “dangerous” and unfit to be President. Goldwater later successfully sued the magazine for libel. The verdict in that case and the episode as a whole was damaging to the reputation of mental health professionals.

            The key rationale behind the Goldwater Rule revolved around the question as to whether youcan secure sufficient, high quality information on a client without the benefit of a clinical interview. There are now various lines of research to indicate the clinical interview should not be considered the “gold standard” of diagnostic assessment and that the Goldwater Rule is antiquated. For example, research on cognitive bias shows that interviewers often display errors in judgement, such as overvaluing flamboyant of dramatic information. Interviewers are also susceptible to impression management, which refers to the interviewee’s tendency to distort their self-report in order to create a good impression. Studies reveal interviewers exaggerate their ability to detect such impression management(9).

            These concerns are amplified when you might be evaluating a psychopath who is so facile with lying and never sees his destructive behavior as pathological. Indeed, in one study (10) with psychopaths, the diagnostician’s ability to predict future behavior was actually diminished when an interview was added to the case file data.

            A recent thorough and scientific critique (11) of the Goldwater Rule notes there are three sources of information to draw upon In making a diagnosis: information from the client (the clinical interview); information from informants (e.g. family, friends, business associates, etc. and, if the public official is high-profile, possibly well-researched biographies); and information from archival sources (e.g. speeches, taped interviews, tweets, court records, real-time observations). A  review of relevant studies indicates that information from informant and archival sources yields higher validity than information from the clinical interview.

            The storehouse of high-quality informant and archival information on Trump is unparalleled. He is arguably the most well-chronicled President/celebrity/person in history. A partial list of informational sources would include: (1) 13 autobiographical efforts (according to his Wikipedia page); (2) 63 biographies, many of which are richly sourced; (3) hundreds of interviews from print, radio and television; (4) over 18,000 tweets since he announced his candidacy; (5) social media material from his Facebook page and YouTube productions; (6) court records (he has been the defendant in over 1500 lawsuits); and (7) investigative reporting of shady financial dealings and alleged criminal activity.

            With such an abundance of information that can be applied to a diagnosable condition where the criteria are operationalized and specific, the core pillar of the Goldwater Rule collapses.

V

                        There is ethical justification to conduct an assessment of the President

                        without his consent. through either a ‘duty to warn’ or ‘duty to inform’

                        principle.

            Just because we can diagnose Donald Trump without interviewing him or securing his consent, the question remains as to whether we should. Those (12) who argue that we should invoke the “duty to warn’ principle. This ‘duty to warn’ principle stemmed from a court decision in California in 1976 (the Tarasoff case), that places an ethical obligation on mental health professionals to warn third parties, if they determine a client under their purview is a threat to harm them. If the President has a psychological condition – the essence of which is a set of personality traits likely to inflict harm on others – then mental health professionals might have an ethical obligation to warn the community. Indeed, 70,000 such professional have signed a petition (13) urging the removal of the President through the 25th amendment, citing his inability to execute his duties in a way that is not dangerous. The ‘duty to warn’ about dangerousness and protect the public health is an obligation that many feel should override the Goldwater Rule.

            ‘A duty to inform’ principle (14) offers another guideline for disclosing mental health information about the President. In the contemporary era, candidates and office holders are expected to disclose critical information about their health and competency. If a candidate for high office was diagnosed with an incurable neurological disease that affected his or her judgement, we would feel entitled to that knowledge. If a candidate were diagnosed with an illness that meant he or she was not likely to survive their term in office, we would likewise feel entitled to that knowledge. Thus, if an individual in public office had a diagnosable personality disorder that pretty much guaranteed that he would inflict harm on others…

            A core value in a democracy is an informed citizenry. Citizens have a right to any information that is relevant and meaningful for those already in office or seeking office for positions of power that affect the general welfare. This would certainly include considerations of conditions that predict dangerousness.

VI

            The President meets the strict diagnostic criteria of the Hare Checklists, the

            gold standard for the assessment of psychopathy. Thus, he  falls in the moderate to

            severe range of the one psychiatric condition that conveys danger to others.

            Having established that we can diagnose the President, and that we should diagnose him under both a duty to warn and duty to inform principles, we can now turn to how to conduct such a diagnostic assessment.

            The first step is to catalogue the mass of information available on Trump. Robert Hare laid down guidelines in his manuals for the checklists, which enabled us to prioritize certain batches of information over others. Information that possesses greater diagnostic value:

  1. Information from his childhood, adolescence and young adulthood. The condition of psychopathy expresses itself early in life. Data is needed from these earlier stages of development to make an assessment.
  2. Information in which the trait is expressed in overt behavior (e.g., an instance of his lying is privileged over an accusation of his lying).
  3. Information that reflects his typical functioning and lifelong patterns vs. descriptions of more flamboyant, occasional behavior.
  4. Information that is well-resourced, substantiated and has some type of external validation.
  5. Behavior that lends itself to coding and thus quantification (e.g., number of documented lies, lawsuits, or grandiose statements).

            The next step is to go through each item of the checklist and cull all the informational data that supports each item on the checklists. Each item is then assigned a score of 0 (trait definitely not present), 1 (there is some data to support the trait, but it is not overwhelming), or 2 (trait definitely present).

            The designation of a 2 for an item deserves some elaboration. Hare emphasizes that a perfect match is not necessary to justify a rating of 2, but rather a “reasonably good match in most essential respects: the behavior is generally consistent with the flavor and intent of the item, even if only a few of the characteristics are displayed, providing that, in the rater’s opinion, they are sufficiently extreme in intensity, frequency or duration.” (15).

            Here are my ratings for the 45th President of the United States:

Hare Psychopathy Checklist — Revised (HCL-R)

  1. Glibness/superficial charm — 2
  2. Egocentricity/grandiose sense of self-worth — 2
  3. Proneness to boredom/need for stimulation — 2
  4. Pathological lying and deception/gaslighting — 2
  5. Conning/lack of sincerity — 2
  6. Lack of remorse or guilt — 2
  7. Shallow affect— 2
  8. Callous/lack of empathy— 2                                                               
  9. Parasitic lifestyle — 0
  10. Poor behavioral controls – 2
  11. Promiscuous sexual behavior – 2
  12. Early behavior problems – 2
  13. Lack of realistic long-term goals – 0
  14. Impulsivity – 2
  15. Irresponsibility – 2
  16. Failure to accept responsibility for own actions – 2
  17. Many short-term marital relationships – 1
  18. Juvenile delinquency – 1
  19. Revocation of parole – 0
  20. Criminal versatility – 2

Total = 32

 

            Hare Psychopathy Checklist – Screening/Clinical Version (HCL:SV)

  1. Superficial/glib – 2 
  2. Grandiose/boastful – 2
  3. Deceitful – 2
  4. Lacks remorse – 2
  5. Lacks empathy – 2
  6. Doesn’t accept responsibility – 2
  7. Impulsive – 2
  8. Poor behavioral controls – 2
  9. Lacks goals – 0
  10. Irresponsible – 2
  11. Adolescent antisocial behavior – 1
  12. Adult antisocial behavior – 1

                        Total = 20

             For each checklist Trump meets the high bar for diagnosis of psychopathic personality disorder. Less than 1% of the population produces such high scores. Please note the average score in the general population on the HCL:SV is 3(!) Trump’s score of 20 is higher than the average score for those incarcerated for serious crimes, or for those receiving psychiatric treatment in either a forensic or civil inpatient facility. A score of 20 is a robust viral load.

            Please be informed.

VII

                       The President is at the mercy of his condition. His diagnosis of

                        Psychopathic Personality Disorder (PPD) enables us to predict,

                        with a notable degree of precision, how he will exercise the duties

                        of the Presidency.

            The formal assessment of Donald Trump places him in the moderate to severe range of psychopathic personality disorder (PPD), His disorder is extreme, rigid and immutable. PPD is a condition as differentiating and undeviating as a primary color. Yes, there are different shades of red, but no one should mistake red for blue or yellow. Code red is who he is, and thus where we are as a country.

            The core traits of callousness, unyielding drive to dominate, and impulsive mode of functioning were never going to yield to the difficult realities of Covid-19 or the civil unrest triggered by the murder of George Floyd. Trump’s particular kind of disastrous response to these emergencies was unavoidable. Up close Trump is dramatic, flamboyant, irreverent and appears to be unpredictable. But, from 20,000 feet up, his behavior is very predictable, including his patterns of chaos. He may proclaim “total authority” to the country, but he is at the mercy of his hard-wired traits. A creature is going to do what a creature does.

            How will his condition play out going forward? In broad strokes, we can count on the following outcomes:

  1. Because of his greater than normal need for stimulation and impulsivity, disruptions to the legal, financial, and administrative functions of our government will accumulate.
  2. In the exercise of his duties – at every choice point – power and dominance will prevail over the welfare of others.
  3. Because of his inability to process emotions related to danger, the government will be lax in response to threat situations.
  4. Because he is undaunted by fear of punishment, norms of trust and decency will continue to erode.
  5. His callous and remorseless disregard for the feelings of others means that vulnerable populations will remain at significant risk.

            As the Covid-19 crisis and injection of authoritarianism into our body politic evolve, Trump’s set of destructive traits will drive his behavior. They will drive his behavior regardless of the damage, danger, or even the harm to his political standing. A creature is…

            Donald Trump, the clinical psychopath, is like a car without brakes (no conscience) or steering (controlled, capable mode of self-direction), careening down the highway, petal to the metal (stuck in an accelerating drive to dominate gear). Whatever comes next (e.g. Covid numbers that further underscore the Administration’s disorganized response; another event that triggers civil unrest; the election) will be met head on with the expressions of these traits – lies, divisiveness, callousness, dereliction and recklessness. l would ask you to buckle up, but this car has no seatbelts.

           

            PPD is a terrible affliction, one for which you would take a bullet to prevent your child from having. Sadly, there is no treatment for the pathogen of PPD. Anyone with this disorder, including the President, deserves mercy. And one expression of such mercy, certainly, would be to remove him from the body politic;  and thus mitigate the damage inflicted by his virulent condition.

NOTES

(Please note: the series of proofs outlined in this article are distilled arguments from a more detailed analysis in A Duty To Differentially Diagnose: The Validity Underpinning The Diagnosis of the President)[1]

 

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