Early Warning
ANTISOCIAL
PERSONALITY--PART II
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In Part I
we described antisocial personality and discussed some of its
roots in heredity
and the social environment. Here we discuss biological
abnormalities
associated with psychopathy and review proposals for its
treatment.
Several
psychological and neuropsychological tests indicate biological
abnormalities
in sociopaths. One common finding is a feeble stress
response
in the autonomic nervous system, which is indicated by a low
heart rate
and a low skin conductance response -- invisible sweating
monitored
by an electrode attached to the palm of the hand. In
measurements
of skin conductance, sociopaths do not show a normal surge
of anxiety
when they are told they are about to receive an electric
shock or
observe someone being given what they think is an electric
shock. A
juvenile delinquent with a relatively high skin conductance
response
and heart rate is less likely to become an adult criminal.
Another
experimental sign of antisocial personality is a weak startle
reflex in
response to distress cues. In one test, subjects viewing
pictures
on a screen are exposed to a sudden, loud noise. In most people
the rate
of blinking immediately increases, and they blink especially
fast if
the picture is unpleasant or upsetting -- a dead body, a crying
child, a
close-up of the muzzle of a gun pointed at the viewer. The
response
of sociopaths is relatively unblinking. In another test, words
with
scrambled letters are briefly flashed on a screen. If the word is
emotionally
provocative ("death") rather than neutral ("paper"), most
people
have more difficulty unscrambling it. But sociopaths decode
neutral
and emotional words equally well. The pattern of their EEGs
(brain
electrical waves) reflects this peculiarity, which suggests that
they are
not sensitive to the emotional connotations of language. Other
experiments
show that psychopaths have difficulty recognizing facial
expressions
of anger, fright, and disgust.
This
imperviousness may explain the sociopath's seeming inability to
learn from
reward and punishment. In one study, children with behavior
problems
were asked to play a game with a deck of blank cards, each of
which had
Yes or No on the back. Every time a child picked up three Yes
cards, he
or she would win a token that could be exchanged for candy.
Three No
cards would cost one token. As the deck was arranged, the
proportion
of Yes cards fell, on average, from nearly 100% at the start
to about
10% at the end, so the longer a child played, the worse the
result.
The children who played the game longest were also the ones who
found it
most difficult to distinguish moral principles from
conventional
rules in stories that were read to them. The implication is
that a
capacity for moral discrimination depends on our ability to
reevaluate
aims by examining the results of actions.
Biological abnormalities and brain
function
These
experimental tests are thought to engage the frontal lobes, the
brain
region (unusually large in human beings) that governs judgment,
planning,
and decision-making. It is sometimes described as the organ
that
imparts feeling to our thinking and makes us think twice before
acting.
Brain scans of sociopaths show lower than average activity in
this area.
In a recent study, researchers found that the volume of
neurons in
the region was 10%-15% lower than average among men with
antisocial
personality (after correction for drug and alcohol abuse and
other
psychiatric disorders).
People who
suffer a serious injury to the frontal lobes, even if they
seem
otherwise intact, may develop some features of antisocial
personality
-- uninhibited behavior, poor planning,, a disregard for the
rights and
interests of others. The most famous example is Phineas Gage,
a
19th-century railroad worker whose frontal lobe was pierced by an iron
spike in
an accident. Although he made a remarkable recovery with no
obvious
permanent damage, his personality seemed different afterward.
The sober,
steady worker became unreliable, drunken, profane, and
eventually
a drifter. Investigators in the 20th century have found
impaired
social behavior and defective social and moral reasoning in
adults who
suffer injury to the frontal lobes before the age of 2.
Patients
with frontal damage often fail the same kinds of tests that
baffle
sociopaths. In one study of people with injuries to the
ventromedial
prefrontal cortex (the region directly behind the eyes),
they were
compared with a normal control group in a gambling game that
crudely
modeled some of the opportunities, temptations, risks, and
rewards to
which we are all exposed in real life. There were two "bad"
decks of
cards that offered a chance of large rewards and even larger
penalties
and two "good" decks that offered smaller immediate rewards
and a
long-term gain. The normal control subjects eventually began to
choose
cards only from the "good" decks -- and they did so even before
they could
say why. Some of them gave no reason, even at the end, beyond
saying
that they had a hunch. The patients with frontal lobe damage did
not have
these hunches, and they were more likely to continue playing
from the
losing decks. When asked why, they said it was more exciting,
but while
playing they actually showed much less arousal (as measured by
skin
response) than the controls. The frontal cortex may be the central
link in a system
that stores knowledge of past rewards and punishments
to produce
the responses that register in the form of intuitions
constituting
what is called good judgment.
Serotonin levels
Another
line of investigation into the roots of sociopathy involves the
neurotransmitter
serotonin. Conduct disorder in boys and impulsive
aggression
in men have been correlated with lower than average levels of
serotonin
in the blood and of its breakdown product in the spinal fluid.
A
variation in a gene that governs the manufacture of a certain
serotonin
nerve receptor is also correlated with differences in
aggressive
behavior. Drugs that enhance serotonin activity seem to lower
the risk
for some kinds of impulsive violence, and regions in the
prefrontal
cortex that control rage and fear reactions have many
receptors
for serotonin. But the relationship between serotonin levels
and
behavior is not simple. There are many kinds of serotonin nerve
receptors,
and brain systems using serotonin interact with others in
complicated
ways. There is no evidence that serotonin activity has any
direct
relationship to the other side of sociopathy -- glibness,
narcissism,
and amorality.
It is
unlikely that brain levels of any neurotransmitter or biological
abnormalities
in any brain region alone determine whether someone will
be
irresponsible, deceitful, callous, or violent. Probably a combination
of
mutually reinforcing influences is at work. Children who are
biologically
vulnerable -- maybe because they are born with an extreme
variation
of a normal uninhibited temperament or some subtle variation
in brain
circuit that includes the prefrontal cortex -- are raised in a
destructive
family and social environment. They develop a conduct
disorder, and
their behavior provokes responses that make the problem
worse --
parents punish them brutally, schools expel them, delinquent
gangs
accept them, alcohol and drugs tempt them, prisons educate them in
crime,
employers refuse to hire them, people they have harmed seek
revenge.
The relative influence of heredity, brain abnormalities, trauma,
upbringing,
and social environment may vary in different individuals who
show the
characteristics of antisocial personality as adults.
Many
methods have been used to treat (or, sometimes, to change and
reform)
sociopaths: family therapy (for the young), individual and group
psychotherapy,
therapeutic communities, education and skills training.
In
self-help groups, the aim is to provide an opportunity for giving and
receiving
candid criticism while avoiding the intolerable subordinate
position
of being a patient. Behavior therapists have tested token
economies
to reward good and punish bad behavior. Cognitive therapists
try to
change psychopathic thinking habits in the hope that feelings and
actions
will follow. Attempts are made to teach patients new ways to
express
their needs and solve their problems, anticipate the
consequences
of their actions and develop self-control, avoid false
assumptions
and expectations of hostility from others. They can be asked
to record
situations that provoke their anger and compare the immediate
rewards
with the long-term disadvantages of impulsive acts.
Some of
the symptoms associated with antisocial personality can be
treated
pharmacologically. Any drug that reduces irritability,
aggressiveness,
and impulsiveness may be useful for one or another
patient
with sociopathic features -- serotonin-enhancing antidepressants
like fluoxetine
(Prozac), antipsychotic drugs, anticonvulsants, or
lithium.
But unless they are under constraint, sociopaths will not
reliably
take any drug that does not give them immediate pleasure. And
there is
always a risk that they will combine prescription drugs with
alcohol,
opiates, or stimulants in dangerous ways.
Many
people who have worked closely with sociopaths doubt the
effectiveness
of any of the standard treatments. These methods may help
some
children with behavior problems and some criminal offenders with
mental
illnesses, but they are all designed for people who can be
persuaded
that they have problems and need to change. The model
sociopath
would never volunteer for psychiatric treatment. In addiction
programs,
where a desire to change is especially important, he is the
least
likely to succeed. If he finds himself in psychotherapy, it is
usually
under coercion, and he will have his own ideas about its purpose
that
rarely coincide with the therapist's. He may dominate a therapy
group by
fascination or intimidation, but he does not learn from others.
Cognitive
or insight-oriented therapy may only show him new ways to
rationalize
and make excuses while blaming and exploiting others. He can
turn
psychotherapy into a power struggle in which he alternates charm
and
flattery with intimidation -- trying to enlist the therapist as an
ally
against his family, the law, the prison system, or society, and
going on
the attack if he is thwarted. If he is intelligent enough, he
can wield
a psychiatric vocabulary to deceive therapists and parole
boards. He
may use psychiatric textbooks strategically in the same way
that, as a
prison lawyer, he will use law books. The Hillside Strangler
of San Francisco
pretended to be suffering from dissociative identity
disorder
(multiple personality) and even succeeded in convincing some of
the
professionals who interviewed him.
A
sociopath's deceit, manipulation, and abuse present many of the same
problems to
a psychotherapist or physician that they create for his
family and
acquaintances. It is not surprising that some say antisocial
personality
is just a label indicating deep dislike. Sociopaths disclaim
responsibility
for their actions, demand special treatment, reject help
offered on
any terms but their own, and blame everyone but themselves
for their
failures. In this situation, it is difficult to maintain a
proper
emotional distance without becoming either over-involved or angry
and
defensive. Therapists have to overcome feelings of repulsion and set
aside
their disapproval. They should remain calm at all times and not
respond to
attacks. They must avoid arguments while firmly rejecting
demands
for a prescription for narcotics, an excuse for an employer, or
an
exculpatory letter to a judge.
Therapists
have to remember that a psychopath's actions convey more
truth than
his words. It is almost impossible to avoid being deceived at
times, and
the effort to uncover every lie is rarely worthwhile. But
even habitual
liars sometimes tell the truth, even malingerers sometimes
get sick,
and real suffering cannot be ignored. When faced with suspect
claims of
anxiety or pain, it is acceptable to prescribe a small amount
of a pain
reliever or anti-anxiety drug. It will usually become clear
before
long whether the symptoms are genuine.
Threats and fears
Psychopaths
can be frightening. Cases are reported in which a prison
psychotherapist
leaves the country because of a prisoner's prediction
about what
he will do when he is released. When threatened, either
directly
or implicitly, a therapist may calmly admit fear and send the
patient
away. It is often prudent to tell a sociopathic patient that in
some
circumstances mental health professionals are required to take
action to
protect potential victims of his threats.
Often the
therapist has to report to authorities, and the sociopathic
patient
knows it -- an uncomfortable position for a healer. But
protecting
others is at least as important as trying to help a sociopath,
and he
needs controls for his own sake as well. As long as he is running
and
dodging, he is unlikely to change. He will not be in a position to
take
responsibility for his actions unless he is subject to definite
rules,
consistently enforced, with reliable and well-timed incentives
and
penalties. But arrangements of that kind are expensive and difficult
to sustain
and are sometimes inseparable from the kind of punishment
that
inspires resentment and a desire for revenge. No program has been
proved to
work for most sociopaths, and the most dangerous are usually
relegated
to maximum-security prisons.
In daily
life, others have to protect themselves. A sociopath's deeds
count; his
words do not. Everyone should be wary of glib charm, a
soothing voice,
a penetrating gaze, dramatic gestures, meaningless
flattery,
and vague and inconsistent responses to personal questions.
The better
people understand their own weaknesses, the less likely they
are to be
exploited. When a sociopath complains about how others treat
him, it is
important not to forget who the real victims are. People who
cannot
avoid being entangled with a sociopath, especially family members,
should set
limits and do their best to avoid being used and abused.
Because it
is in the nature of sociopaths to avoid being seen for who
they are,
what they say about themselves in interviews is not reliable.
As a
result, the long-term outcome of antisocial personality is not easy
to judge.
But there is evidence that sociopaths begin to "burn out" in
their
forties, at least as far as impulsive aggression and crime are
concerned.
The underlying character traits are probably more persistent.
In a 16-
to 45-year (average 30-year) follow-up of men with antisocial
personality
admitted to a state psychiatric hospital, researchers found
42% not
improved, 31% improved, and 21% with no antisocial symptoms and
no current
psychiatric disorders or problems (by American Psychiatric
Association
definitions). The original group in the study consisted of
71 men;
only 26 could be traced and interviewed, but the results are
still
worth noting. The researchers were able to get some limited
independent
verification of the men's statements from acquaintances,
family
members, and police and medical records. A good or bad outcome
was not
related to IQ, family psychiatric history, history of
imprisonment,
or treatment, but alcoholism made everything worse.
Antisocial
personality is a problem that is difficult to think about
therapeutically.
When a person hurts others repeatedly in many ways with
no
apparent regret, we ordinarily do not want to help him, especially if
we suspect
that he will be unreasonably demanding, ungrateful, and
almost
impervious to change. But sociopaths can do with attention, not
just
disdain. The effort to change them is worthwhile if only to protect
others.
And however difficult it may be for them to acknowledge, change
is
ultimately to their own advantage as well.
For Further Reading
Brennan PA
and Raine A. "Biosocial Bases of Antisocial Behavior:
Psychophysiological,
Neurological, and Cognitive Factors." Clinical
Psychology
Review (1997): Vol. 17, No. 6, pp. 589-604.
Hare RD.
Without Conscience: The Disturbing World of the Psychopaths
Among Us.
Guilford, 1998.
Millon T,
et al., eds. Psychopathy: Antisocial, Criminal, and Violent
Behavior.
Guilford, 1998.
Reid WH. Unmasking
the Psychopath: Antisocial Personality and Related
Syndromes.
W. W. Norton, 1986.
Vaillant
G. "Sociopathy As a Human Process." Archives of General
Psychiatry
(February 1975): Vol. 32, pp. 178-83.
Source:
Harvard Mental Health Letter, Jan2001, Vol. 17 Issue 7, p1, 4p.