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.
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. They established the first systematic effort to assess and study psychopathy.
Hare’s 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 of the condition. As a result, psychopathy has benefited from more attention and research than any other personality disorder. In addition to its solid psychometric qualities, the checklists 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 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. The checklists should only be administered by a qualified professional, with advanced training in the use of the checklists.
Yes. ASPD is a broader diagnostic category compared to PPD. Whereas 4% of the population meets diagnostic criteria for ASPD, only 1% does for PPD. The diagnostic criteria for ASPD – listed in the current Diagnostic and Statistical Manual – focus more on criminal and antisocial behavior; whereas the diagnostic criteria for PPD focus more on specific clusters of destructive personality traits. The great majority of criminals qualify for ASPD, while only 25% of criminals meet diagnostic criteria for PPD.
Most psychopaths are not criminals. However, all psychopaths display predictable patterns of harmful behavior. Overall, psychopathic personality disorder is considered a more well-defined, but also a more extreme and virulent condition than antisocial personality disorder.
As is the case with virtually all psychopathological conditions, psychopathy appears to be the result of an interplay between nature (genetics) and nurture (environment). However, with psychopathy, it appears that nature is the more significant contributor. A number of large scale studies have demonstrated that the heritability of psychopathy appears to be over 50%. There has been much less success in identifying environmental factors. A number of different types of childhood maltreatment have been investigated but, so far, no direct link to psychopathy has been found.
Thus, psychopathy appears to be, to a significant degree, a condition “of the blood’. That something contributing significantly to psychopathy is inherited has been proven. But what is that something?
A different brain is the short answer. There is accumulating evidence that the brains of psychopaths are different; and different in a way that lines up with the three core traits of psychopathy – remorselessness, lack of empathy, and impulsivity. Psychopaths display abnormalities in the limbic area, amygdala, and prefrontal cortex. These are areas of the brain that are associated with the capacity to have feelings of guilt and shame; the ability to empathize with others; and the capacity to modulate impulses.
It is difficult for one to overcome the burden of these neurobiological deficits. It appears that a very small percentage of us are born with a predisposition that is antithetical to much of what we associate with being human.
There is no successful treatment for psychopathy. A range of psychotherapeutic and psychopharmacological treatments for psychopathy have been evaluated. None have been found to be effective.
Indeed, some studies have indicated that therapy actually increases the risk of recidivism for incarcerated psychopaths. Investigators concluded that, although psychopaths appear to conform to the process of therapy, beneath the surface they are learning more effective ways of manipulating and deceiving others and thereby ‘gaming the system’.
Successful therapy requires motivation to change, the capacity for insight, and the ability to form a collaborative relationship. Unfortunately, these capacities represent core deficits for the psychopath. To ask a psychopath to profit from therapy is like asking a totally blind person to participate in a visual training program, in which the pre-condition for success in such a program is to have partial sight. Psychopaths lack the basic psychological infrastructure to benefit from therapy.