Is the label «Psychopath» more a moral denunciation than a clinical diagnosis?

However, any individual, which shows such symptoms, may be diagnosed with antisocial personality disorder (ASPD), according to DSM-V, or with dissocial personality disorder (DSPD), according to Chapter V of ICD-10, although the researches displayed that “most psychopaths meet the criteria for ASPD, but most individuals with ASPD are not psychopaths” [8, p. 2]. For example, Hare [8] writes that if assessing psychopathy in criminal population with the use of the Hare Psychopathy Checklist: Revised (PCL-R), then “between 15% and 20% of offenders receiving a score of at least 30, the cut-off for a diagnosis of psychopathy,” whereas “the mean scores for offenders in general and for non-criminals are around 22 and 5, respectively”. Blair [1] supposes that psychopathy and ASPD should be separated altogether due to the main problem with ASPD is “that allowed antisocial individuals with completely different personalities, attitudes and motivations to share the same diagnosis” [8, p. 2]. Besides, ASPD is the most common personality disorder among the criminals, and “almost any offender in a correctional setting is hypothetically entitled to a diagnosis of ASPD” [30, p.149], but there are also many psychopaths in non-criminal populations. For example, Cleckley [2] believed that “psychopaths could be found in society’s most respected positions: as doctors, lawyers, politicians, and even as psychiatrists.”

Lykken ([17] assured that psychopathy is one of two different subtypes of ASPD, and the second is sociopathy because psychopaths are impulsive, inclined to risk-seeking behaviour and incapable to adopt social norms whereas the sociopaths in general are temperamentally stable and much more affected by negative social factors like poverty and problems within their families. It is partly true so long as there are two key conceptions of psychopathy subtypes, and the first one is focused on “how the individuals with phenotypically similar symptoms differ etiologically” [25, p. 177]. According to Karpman [14], people with psychopathic personalities may be divided into two groups – ‘primary (impulsive or antisocial) psychopaths’, who are pure psychopaths, and ‘secondary (symptomatic or narcissistic) psychopaths’, who are sociopaths. Cleckley [2] remarked that “the true difference between them and those who continually go to jail or to psychiatric hospital is that they keep up a far better and more consistent outward appearance of being normal”. Nevertheless, Hare [10] thinks that sociologists may prefer the term ‘sociopathy’ as well as psychologists the term ‘psychopathy’ since the difference between them both “reflect the user’s views on the origins and determinates of the disorder”. The second conception is focused on “describing phenotypical differences among individuals with psychopathic traits by referencing comorbid traits of other personality disorder” [25, p. 177] and includes two major theories. The first theory is focused on “recurring patterns of overlap between psychopathic and other traits” [25, p. 177]. It is represented by Murphy and Vess’s four subtypes of psychopathy based on DSM-V’s Cluster B personality disorders – sadistic, narcissistic, antisocial and borderline. The second one is all about “psychodynamic personality organization” [25, p. 177], and represented by Millon and Davis’s ten subtypes of psychopathy, which are similar to Murphy and Vess’s four subtypes, but much more detailed and specific.

It was found by Herve and Hare [13] in the course of their joint research that “a very low base rate of manipulative psychopaths is in a recent sample of offenders”, but many primarily psychopaths “may be abundant in psychiatric samples”. So, the central question for subtyping researches is how to “identify ‘subclinical’ and ‘successful’ psychopaths in community and non-correctional samples”, not “finding psychopaths under every stone” [25, p. 187], if, as a rule, psychopaths do not seek for help. Firstly, “people with personality disorder do not believe that they have a problem, it is the rest of world that has it all wrong” [15, p. 96], and secondly, “any control, however mild, irritates the psychopath, and he reject it” [21, p. 12]. What is more, psychopathy is generally untreatable because “there is nothing ‘wrong’ with psychopaths in manner of a deficit or impairment that therapy can ‘fix’” [11, p.568]. Also, it still remains unknown what exactly provokes the development of psychopathic traits, which biological, sociological, psychological or neurological causes, although “the studies repeatedly indicate that painful treatment results in what has been called ‘aggressive action’” and many aggressive psychopaths were “severely rejected, physically beaten, and emotionally deprived by parents” in childhood [21, p. 11].

However, childhood abuse is not a privilege of psychopathic children only, so “deviant behaviour, then, is inadequate criterion of psychopathy” [21, p. 8], and it is not reasonably at all to label anyone as psychopath on the ground of his antisocial behaviour. Unfortunately, in the twentieth century “psychiatric diagnosis was an impressionistic art form and even experienced practitioners often could not agree in classifying the same patients except in a very general way”, and many “dangerous or persistent lawbreakers were labelled variously as psychopaths or sociopaths with negligible diagnostic consistency or clarity” [18, p. 3]. Moreover, Lewis [16] pointed that “the diagnostic concept at first called ‘moral insanity’ has been troubling” the psychiatrists due to “its outline will not be firm until much more is known about its genetic, psychopathology, and neuropathology”, and, undoubtedly, it gives a lot of scope for flight of fantasy. So, to be diagnosed with ASPD, for example, since there is no such an official clinical diagnosis as ‘psychopathic personality disorder’ and psychopathy is a subtype of ASPD, an individual must meet the requirements for this personality disorder which are listed as diagnostic criteria in DSM-V. Lykken [18] noted that “no special psychiatric knowledge or insight is required to make a diagnosis on the basis of these guidelines” because they focus on “disregard for the law, aggressive behaviours, and violation of social norms”, not on “the lack of empathy and the glibness associated with the most concepts of psychopathy” [27, p.231]. Therefore, any person, if his behaviour does fit in with obvious symptoms of ASPD, may be theoretically labelled as a ‘psychopath’, not being psychopath in point of fact. Hare [9] and his colleagues “have taken great pains to differentiate between psychopathy and ASPD when clinicians use the labels as if the constructs they measure were interchangeable”.

Gunn [3] wrote that “in such cases we are sometimes told that the patients have a ‘dual diagnosis’” and, apparently, “the label ‘psychopathic’ is not being applied to assist with the understanding of the patient’s psychopathology, it is simply used as a mechanism to reject these patients”. In other words, this label implies in some ways that this patient is ‘untreatable’. It leads to “a stereotyped approach to treatment that ignores or misses the important variations among patients” [3, p. 33] despite the fact which says that if “some treatments that are effective for other offenders are actually harmful for psychopaths, it does not mean nothing can help” [11, p. 568]. Harris and Rice [11] supposed that “tightly controlled behavioural programs with contingences remain in effect both inside and outside institution” for antisocial and aggressive psychopaths who cannot control their impulses dangerous for the society in whole or small local communities. What is more interesting, most researches and mental health professionals are all reluctant to discuss psychopathic children although the specific personality traits “begin to manifest themselves in childhood” [9, p.194]. So, if there is a chance to influence the development of psychopathy, it might be, probably, done at an early age even if the problem is complicated by “a general failure to differentiate the budding psychopath from other children who exhibit serious emotional and behavioural problems”[9, p.194]. From this perspective, the term ‘psychopath’ seems to be “a trigger for rejection” [3, p. 95], although mental hospitals are supposed to be “staffed by experts in curing diseases” [30, p. 154] who are meant to help individuals suffering from psychological problems. Or it is “a largely moral term” [3, p. 95], which symbolises helplessness what psychiatrists might feel facing the compound cases than a clinical diagnosis itself.