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How One Becomes a Psychopath: Antisocial Personality Disorder Revisited

Uploaded 4/22/2023, approx. 45 minute read

Okay, some of you have written to ask me for a longer video, talk about Masochistic Personality Disorder.

But being who I am, I'm going to oblige you. I'm going to give you an extra long video because I'm the nicest ever former visiting professor of psychology and visiting I am right now. I'm also the author of Malignant Self-Love: Narcissism Revisited.

And today we're going to discuss antisocial personality disorder psychopathy.

Are they real? Is there such a thing? And if they are real, how to become one?

You can't say you're not having fun with Sambhakni.

Okay, shoshanim, shvanparnim, khabivim, kmaadmaadim, madanim, parashoshik, don't ask. The list is way too long even for my 190 minimum IQ.

The problem with antisocial personality disorder, as it is defined in the Diagnostic and Statistical Manual, Edition 4, Text Revision, Edition 5, Text Revision, is that the diagnosis relies on criteria which are behavioral.

In other words, to qualify to receive a diagnosis of antisocial personality disorder, you must behave in certain ways.

The criteria are not based on anything intrinsic. They are not even based on any clinical observations. They're based on behavior, personal history, autobiography.

And this raises the question, if you behave in a certain way, does that make you mentally ill?

For example, if you hate authority, aka, contumaciousness, if you are defiant, if you are reckless, if you don't care for the consequences of your actions, if you reject your life, if you're violent and aggressive, if you are pathological something, a pathological liar, a pathological gambler, if you lack impulse control and behave in ways which are deleterious and detrimental to other people.

It's all bad, of course.

But does that make a mental illness? Shouldn't a mental illness be a clinical entity? Shouldn't it be almost medical? Shouldn't we be able to diagnose mental illness regardless of specific socially rejected behaviors? Aren't we pathologizing socially unacceptable behavior? Aren't we pathologizing a refusal to sublimate, a refusal to play by the rules of society? Aren't we encouraging conformism, sheeple mentality?

In short, isn't the diagnosis of antisocial personality disorder, isn't it a form of social control? Isn't it an instrument to subdue and subjugate the wayward, those who don't play by the rules, those who don't obey the law, those who reject and resent authority, those who undermine the pillars of our civilization, those who challenge social mores and conventions, those who are mavericks and even entrepreneurial in many ways?

Why do we pathologize them? Isn't it a tool of society rather than a proper clinical entity?

I personally happen to think that antisocial personality disorder is BS. It's not a mental illness. It's not a diagnosis. It should not be a diagnosis. It should vanish.

In my view, it's completely wrong. I think it's what we call a culture-bound syndrome.

In other words, a set of traits and behaviors that we find reprehensible, that society frowns upon, that we would like to eliminate and eradicate because people get hurt or damaged or broken.

But the proper place for this is in criminal courts, not in diagnostic manuals.

When we start to mix it or confuse it or to mix it or to conflate it to the criminal system and the psychological system, what we get is dictatorship.

In Soviet times, in the USSR, dissidents, people who oppose the regime, they were diagnosed as mentally ill and they were placed in mental asylum for the rest of their lives.

We are going that way.

There are hundreds of thousands, if not millions of people in prison just because they don't agree with the rules and the laws of society.

Now, many of them spend time in prison only to find out that they were right.

For example, homosexuals were incarcerated. It was a crime for well over 300 years in multiple locations, including very civilized places like the United Kingdom.

It's not a crime now. It's not even a mental illness. It used to be homosexuality. It used to be defined as a mental illness until 1973.

The DSM-3 removed it.

Now, people who, for example, smoked cannabis or marijuana, they went to prison only for the laws to change. Laws are not written, are not cast in stone. Laws don't come from high up. Laws are human inventions. Laws reflect ever shifting consensus.

So to create a mental health diagnosis based on behaviors that are today unacceptable and tomorrow mainstream, that's crazy and undermines the objectivity and foundation of psychology.

Still, I'm going to review the literature for you today. I'm going to try to make sense of some of the aspects of antisocial personality disorder and psychopathy.

Before we proceed, there's no such thing as sociopathy in proper rigorous clinical literature.

Media figures use it. It's media hype.

And some scholars from time to time degenerate or regress into using the term. It's meaningless. It's not a clinical thing. It's like empath, nonsense, nonsensical, or emotional flashback. These are nonsensical things.

So I'm going to limit myself to psychopathy and antisocial personality disorder.

Mind you, even psychopathy is not considered a clinical entity by the vast majority of practitioners in the United States or in North America.

Successive committees of the Diagnostic and Statistical Manual refuse to incorporate the diagnosis of psychopathy in the DSM.

So it's not there. There's no such thing in the DSM. There's only antisocial personality disorder.

Robert Hare, Babiak, and quite a few others, Dutton, quite a few others. They're the proponents and the advocates of the psychopathy diagnosis as distinct from antisocial personality disorder.

But the debate is still raging. I think they're right. I think the research of things is a psychopath.

But that's only my personal unqualified opinion.

And as I said, the majority of the profession disagree. They think there's no such thing.

No such thing.

So let's then write.

Antisocial personality disorder is a pattern, a pattern of socially irresponsible, exploitative, and guiltless behavior. All three elements must exist.

Irresponsibility, recklessness, damaging others, and so on.

Exploitativeness, goal orientation, and a lack of remorse or guilt or shame. Non-negative affectivity associated with negative actions, actions that are socially perceived as negative.

Antisocial personality disorder usually occurs, is comorbid with other issues, addictions, for example.

And so it's very difficult to disentangle the impacts and effects of substance abuse from the impacts and effects of the alleged clinical entity, antisocial personality disorder.

So contrary to what many self-styled experts will tell you online, the rates of suicide, homicide, and accidents among psychopaths, collectively known as unnatural deaths, these rates are excessive.

Antisocial personality disorder is an excellent predictor of poor treatment outcomes. They're impossible to treat. And the reason that ASPD is, and I'm going to use ASPD for now, make the video shorter, Antisocial personality disorder equal ASPD. Got it pigeons.

Okay.

So ASPD, and the reason that it's very difficult to treat ASPD is that ASPD is actually a childhood disorder.

It starts very, very early in life, usually around ages six to eight. And at these ages, it's not called psychopathy, it's called conduct disorder. If it persists until age 18, you graduate from conduct disorder to ASPD, if the antisocial behaviors persist.

So how do you treat someone that has been an integral feature of one's life from age six or eight?

It's very difficult to disentangle, break apart the identity of the person from these dysfunctional or at the very least antisocial behaviors.

Yeah, I heard some noise.

So it's entrenched. It's entrenched, it's chronic, it's lifelong, but exactly like borderline personality disorder, it improves with age.

The early of the onset, the poorer the diagnosis.

Now I mentioned this identical pattern of lifespan development, both antisocial, both ASPD and BPD, borderline personality disorder, remit with age to the point that we can no longer diagnose in people usually above the age of 45.

This leads many scholars to speculate that both disorders, BPD and ASPD, are actually brain abnormalities, forms of brain malfunction, dysfunctional, structural and functional.

And so there is a body of literature that tends to support this.

The brains of people diagnosed with antisocial personality disorder are very different to the brains of normal, or shall we say healthy people.

And the functioning of these brains is different. And the physiology of people with ASPD is different.

For example, perspiration patterns, reactions to fear, amygdala and so on. And skin conductance, they're all very different.

That's why psychopaths can defeat a polygraph test, can defeat a lie detector.

And so as the person with ASPD grows older, usually the antisocial aspects, because there are others which we will deal with later, the antisocial behaviors and aspects of the disorder tend to ameliorate.

Psychopaths who get married, find a steady job, are incarcerated early on, end up in prison at an early age, or adjudicated if they are children, socialize. These psychopaths are likely to recover, to lose the psychopathy, to lose the antisocial features, earlier.

The symptoms of antisocial personality disorder, as I said, are very society-oriented. I mean, just listen to the word, antisocial. So who is defining the disorder?

Society does. Do you conform to the law? Do you observe the law?

No. You're a psychopath. Do you fail to sustain consistent employment?

You're a psychopath. Do you manipulate other person with gain? Do you deceive other people? Do you fail to develop stable interpersonal relationships?

You're a psychopath.

Now, the lifetime prevalence of ASPD is anywhere between 2 to 4 percent in men and 0.5 to 1 percent in women.

So it's a men's thing.

Psychopathy is definitely a men's thing, as opposed to narcissism and borderline, which are equally represented among men and women, psychopaths are overwhelmingly men.

The prevalence peaks between 24 and 44 and drops precipitously between 45 and 64.

Male to female ratio is anywhere between 2 to 1 and 6 to 1, depending on the assessment method and sample characteristics.

And the prevalence of ASPD varies with the setting.

But in prisons, for example, there have been studies that the prevalence of psychopathy among prisoners is about 80 percent.

As I mentioned before, ASPD is associated with addictions, major depressive disorders, bipolar disorder, anxiety disorder, somatic symptom disorders, somatization, substance use disorders, gambling disorder, sexual disorders.

So it's a rainbow coalition of disorders which renders the ASPD diagnosis even more suspicious.

It seems that ASPD borrows elements from these comorbidities and makes it exceedingly difficult to tell them apart.

People with ASPD are at risk for traumatic injuries, accidents, suicide attempts, hepatitis, and HIV. People with ASPD use a disproportionate share of medical and mental health services. And they have been identified, as I said, as a predictor of poor treatment response, only in certain populations, by the way.

So ASPDs die early, and the rates of mortality among them, among people with ASPD, the rates are much higher.

But we are beginning to discover connections between ASPD and other surprising chronic illnesses.

For example, there's a strong connection between ASPD and diabetes. What we don't know is whether this is the outcome of neglect.

Psychopaths don't pay attention to their own health. They fail to comply with medical regimens. They neglect their own medical problems.

This could be one explanation.

But there may be other explanations.

And we're just starting to explore this exciting field of the medical background, the physiological and physiopathological background for antisocial personality disorder, antisocial behavior in general, and psychopathy.

Nearly 80% of people diagnosed later in life with antisocial personality disorder, 80%, as age zero, display their first symptoms no later than age 11, usually age eight, but no later than age 11.

Boys develop symptoms earlier than girls. And girls usually don't develop symptoms until puberty.

Studies by Robbins that a child who makes it to age 15 without exhibiting antisocial behaviors will not develop psychopathy.

So children who do not develop conduct disorder by age 15 are exceedingly unlikely, vanishingly unlikely to develop ASPD.

ASPD, therefore, is a childhood disorder, exactly like pathological narcissism, exactly like borderline. Borderline develops at age 12 among girls.

Narcissism is a reaction to early childhood abuse. These are all childhood disorders.

You could generalize and say that cluster B is not an adult disorder, but a childhood disorder. These are not adult disorders, but childhood disorders.

And this is one of the philosophical pillars of my work when I suggested that the treatment of people with cluster B personality disorders should be founded on child psychology. They should not be treated as adults because they are not.

The presence of conduct disorder in childhood is a robust predictor of ASPD in adulthood.

The DSM-5 definition of ASPD actually requires a history of childhood conduct disorder. The diagnosis is used for persistent and serious childhood behavior problems, including cruelty, sadistic cruelty.

Once a child passes age 18, if the behavior problems are persistent, then it's ASPD.

The numbers are staggering. About 25% of girls and 40% of boys with conduct disorder will later meet the criteria for antisocial personality disorder.

Let's discuss a bit the history of antisocial personality disorder.

I have another video on this channel where I discuss the history of personality disorders in general.

Psychopathy was actually the first personality disorder ever to have been described. This video that I have here on the history of personality disorder disorders is actually a video which deals with the history of the very concept of psychopathy.

Today we are going to deal with the history of the diagnosis of antisocial personality disorder.

In the 1950s, there were people like Harvey Klechly and others, Robbins, Gloox, Gloox, and Gloox. At Harvard, Washington University, St. Louis, and other places, these scholars, independently, by the way, demonstrated that there is a continuity between adult and childhood behavior problems.

The work of these researchers influenced the diagnostic criteria which were first incorporated in the DSM-III, 1980.

Gloox, for example, they followed 500 boys between the ages of 10 and 17. These were boys who were judged officially delinquent by the Massachusetts Correctional System. The boys were interviewed at ages 25, 32, and 45.

It's a longitudinal study, one of the largest.

In the 1990s, Samson and Lauv reanalyzed the Gloox data and they were able to confirm their findings.

Those of you who want to follow this amazing study, it was published in a book called Unraveling Juvenile Delinquency.

So, severe antisocial behavior in childhood, problems which are serious enough to constitute legal delinquency, this was strongly linked to adult criminality and/or deviant behavior.

Arrests between the ages of 17 and 32 years were three to four times more likely to occur in men with a history of delinquent behavior than in their non-delinquent peers.

Unraveled antisocial behavior also predicted many other things, educational attainment, economic status, employment, family life in adulthood.

Samson and Lauv concluded that varied outcomes correlated with childhood behavior are all expression of the same underlying trait, although they didn't exactly identify the trait.

Samson's work was much more influential.

He studied 524 subjects in a child guidance clinic between 1922 and 1932, and he followed up on them in the 1950s.

She described the study in a book called Deviant Children Grow Up.

The children were on average 13-year-old when they were seen at the clinic. About three quarters of them were boys, and most of them were referred by juvenile courts.

Robbins concluded that ASPD is chronic, persistent, and seldom remits.

We now know this to not be true.

And so, this was a background in the 1950s.

We had Blackley's, Masterpiece, Mask of sanity, amazing book, but very literary, not exactly a rigorous clinical study. And we had rigorous studies by Robbins, Glukes, and many others.

The problem was, then, and is now, that many prospective studies involved non-representative samples.

People who have been hospitalized, prisoners, people who have been adjudicated, and people who have been hospitalized, these are non-representative samples. They don't represent the general population. These are self-selecting samples in many ways, and the definition of antisocial personality disorder has evolved. And so, it makes it very, very difficult to interpret earlier findings.

Many prospective studies used a limited number of predictive variables, for example.

And so, let's go back to Robbins' studies.

Among the 524 subjects, 94 qualified for an ASPD diagnosis, in adulthood, 82 of whom were interviewed 30 years later. These people were in their 30s. They were in their 40s.

Robbins concluded that 12 percent have remitted, only 12 percent. There was no evidence of antisocial behavior. Another 27 percent have improved, but have not remitted. Sixty-one percent were un-improved or even became worse. Their antisocial behavior became much more egregious.

The average median age, actually, of improvement was 35 years old.

But Robbins noted that there was no age, I'm quoting here, no age beyond which improvement seemed impossible. And that the subject had improved did not mean that the disorder was no longer a problem.

She wrote the following, I'm quoting, "The finding that more than one-third of the sociopathic group had given up much of the antisocial behavior does not mean that at present they are strikingly well-adjusted and agreeable persons. Many of them report interpersonal difficulties, irritability, hostility toward wives, neighbors, and organized religion. They are in many cases no longer either a threat to the life and property of others, nor a financial drain on society, but still not people you would like in your life or to cross swords with." Let's progress a bit.

The Iowa antisocial follower.

Black and his associates followed up on 71 men who had been psychiatrically hospitalized at the University of Iowa between 1945 and 1970. These men met the criteria for antisocial personality disorder in the DSM-3. The criteria were applied retrospectively, but still there was a good match. The researchers were able to trace over 90% of the men and their sufficient information, about 45 of them, regarding the outcomes of the hospitalization 29 years earlier.

The mean age of the men was 56 years in the follower.

With ratings similar to those used by Roberts, Black and his associates concluded that 27% of the subjects had remitted, 31% had improved but not remitted. And 42% were un-improved or even worse.

Subjects that were most likely to improve were the least symptomatic at baseline and had achieved an older age by the time of the follow-up.

Black concluded that many of the antisocial behaviors present were still present at follow-up.

Allow me to quote a paragraph from the study.

Although most of our subjects were no longer having frequent confrontations with the police, they continued to have enduring problems with poor occupational performance, social isolation, marital discord, poor family relations and substance abuse.

The kind of person he would like to marry or have as a neighbor.

Hm, joking.

Black compared the course of the antisocial men to people with schizophrenia or depression as well as to healthy control subjects.

Because there was a study called IOR 500 and he took the data from there.

Okay, so all the subjects were hospitalized in the same facility so there was no treatment variability. You couldn't say, well, they are different because they spend time in a different hospital and each hospitalizes on procedures and level of quality and so on and so forth.

No, they were all in the same unit, they were all in the same facility.

So that eliminated a lot of bias.

So antisocial men fared less well than depressed subjects and not to mention healthy control subjects.

When you review the marital situation of psychopaths, occupational, psychiatric adjustment, they were even worse than depressive people.

They function, people with antisocial personality disorder function better than people with schizophrenia in their marital status and housing, but not when it came to occupational status and aggregate psychiatric symptoms.

This is shocking. It means that people with antisocial personality disorder, psychopaths, are worse off, worse off, psychiatrically than schizophrenics.

And the schizophrenics can hold the job much better. They're much more stable occupationally than psychopaths.

It's the pits. It's even much worse than the narcissists.

I have a video on this channel, how to tell a narcissist apart from a psychopath, how to tell them apart.

And I coined the phrase Island of Stability.

Narcissists have an island of stability, a stable marriage, but many careers, a stable career, but many marriages.

One part of their lives, the life of the narcissist, one part is always stable. It grounds him. It's an anchor. And all the other parts are in chaos.

The psychopath, everything is in chaos. Everything is in chaos. The psychopath, he has his life time and again. He can persist for 10 years in doing something and he would look like the most stable, reasonable, rational, wise man. And then he would destroy everything in an orgy, explosive orgy of rage and envy and hatred and just pure, simple self destructiveness, which he collectively called a rejection of life.

So that's a psychopath for you.

Even people with psychosis don't behave this way.

A psychopath is like a tornado that consumes the entire neighborhood and then consumes itself.

It's really bad in terms of functioning.

It doesn't mean that it's a mental illness, mind you, that you don't function well in any given society, in different values maybe, or that doesn't make you mentally ill.

But still there's no debate that people with antisocial personality disorder malfunction, that their functionality is much reduced, that they have a problem being self efficacious, pursuing their own goals successfully, their goal oriented, their goal obsessed.

They are sometimes invested emotionally in the very process of pursuing goals, but they are losers, they're failures. Even when they're exceedingly successful, they end up ruining everything.

Look at Adolf Hitler. And to some extent, no comparison.

Donald Trump, who is possibly a psychopathic narcissist, possibly.

So by the way, everything I'm saying about psychopaths applies to psychopathic narcissists.

Psychopathic narcissists are narcissists who use, leverage psychopathic methods and techniques and survival strategies and traits to obtain supply.

So they are essentially outwardly psychopaths for all intents and purposes.

Both Black and Robbins found that a sizable percentage of people with antisocial personality disorder improve or remit with advancing age, about half according to them.

Today we know the number is higher.

And this finding was consistent with crime statistics.

Crime statistics showed that arrests peak among people in their late teens and then decline. Few arrests occur in older adults. When arrests occur, they're due to conduct offenses such as public drunkenness, not usually owing to violent crimes.

While the aging antisocial person is not as problematic community-wise, many remain troublesome in their families, among their neighbors and coworkers.

So it's not, antisocial behavior doesn't disappear. It's just like the target group becomes much smaller while the teenage psychopath and the young adult psychopath, they're likely to target society as a whole.

The aging psychopath will target his wife or a neighbor, a pesky neighbor or a hated boss or a coworker.

Okay?

So it's like a constriction of life.

Psychopath's life is constricted because he keeps suffering losses. He keeps getting punished.

It's like a Pavlovian reaction. It's like a dog that's being beaten on the nose, struck on the nose. The dog learns to not pee on the carpet.

Psychopaths learn that all of life is a huge carpet and peeing on the carpet has its consequences. When you pee on society, society gets wet. When society pees on you, you drown.

So many of these people end up being indigent and they draw on public resources for survival. Those who do improve are still unable to regain lost opportunities in education, employment, domestic life. It's too late.

When these people wake up, when they have lost the antisocial behavior, when they want to integrate and to conform, their discovery is too late. They don't have the proper education. They've never been gainfully employed or consistently employed. The domestic life is ruptured and ruined.

And there are numerous angry people after them. They create hordes and herds of enemies everywhere.

Some people, for these people, improvement in the psychopathic condition simply means somehow subsisting or living in society's margins until they die.

This is a sad picture of the aging psychopath.

What about young people?

The developmental trends study began in 1987. It involved 177 boys in Pennsylvania and Georgia. These boys were aged 7 to 12 and they were followed up at regular intervals into early adulthood.

The purpose of the study was to document the course of disruptive behavior over time and the interaction with other mental health disorders or even other physiological disorders.

The boys were recruited from university clinics. They have been referred to these clinics because of some disruptive behavior disorder. Often they were misdiagnosed with attention deficit hyperactivity disorder or conduct disorder.

This study showed that boys with early onset of symptoms had a faster progression to more serious problems than boys whose problems emerged at a later age.

The earlier the behaviors, torturing animals, exploiting others, stealing petty thievery, lying, the earlier this behavior starts, the worse the prognosis, the worse the outcome in later life.

Early onset is the number one, two and three predictor of how you're going to end your life as a psychopath.

And so physical fighting, for example, predicted the onset of conduct disorder more than any other symptom. Oppositional Defiant Disorder was a developmental precursor to conduct disorder in some boys.

conduct disorder, as I repeatedly said, is a great predictor, is predictive value when it comes to later diagnosis of ASPD in adulthood.

The Pittsburgh Youth Study was a longitudinal study of inner city boys. It began also in 1987.

The aim was to trace the development of antisocial and delinquent behavior from childhood to early adulthood.

Among boys in the first, fourth and seventh year in the Pittsburgh public schools, 1,517 were screened and the 30% most antisocial were selected for follow-up along with 30% of the remainder as a control group, in effect.

The boys ranged in age again from seven to 13 at intake.

In this study, the researchers showed, demonstrated that problem behaviors occurred along a developmental trajectory from childhood to adolescence.

The onset of minor covert acts such as lying or shoplifting, these tended to occur before the onset of more serious transgressions such as property damage.

Property damage in turn occurred before the onset of moderate to serious forms of delinquency, including sexual offenses.

Moffitt and colleagues, Moffitt, Hodges and others, they suggested that ASPD is actually highly stable in a small percentage of men and women and their behavior problems are extreme.

They said that this kind of ASPD does not emit, does not heal spontaneously.

And they called it life course persistent ASPD.

And there was a study called the Dunedin Longitudinal Study in New Zealand. And Moffitt and his colleagues traced the outcome of 1,037 children from age three to age 32.

So this is the first study, or the only study, the time of rule, where they've examined children younger than 70 or six years old.

So most antisocial youth with behavioral problems were categorized as having an adolescence limited form of antisocial behavior.

This is a type of less severe antisocial behavior.

It arises in the context of teenage peer group pressure. It's important. It's not internal. It's brought from the outside.

These teens typically have little or no history of early antisocial behavior. They improve on their own.

And most children, about 60% of children with this type of conduct behavior, they do not develop adult ASPD.

So what are the outcome predictors for antisocial personalities?

She's found that most of the children improved as they grow older and did not become adults with antisocial personality disorder.

She concluded that variety and severity of childhood behavior problems are the single best predictors of adult antisocial behavior.

She wrote this, "No patient without moderately severe antisocial behavior is measured by having six or more kinds of antisocial behavior.

So no patient without these moderately severe antisocial behavior.

Let's regress a bit.

She defined moderately severe antisocial behavior as behavior that has six or more kinds of antisocial behavior, four or more episodes of antisocial behavior, or an episode of such behavior serious enough that it might have led to a court appearance.

She says, "No patient without these was diagnosed with a form of antisocial personality as adult."

So you need to be really, really bad as a child and even worse as an adolescent. You need to be cruel and sadistic and exploitative and criminalized. And you need to be dysempathic and reckless and defiant and authority rejecting, contumacious. You need to be all these in childhood and adult to become a lifelong psychopath.

Otherwise your chances to not develop antisocial personality disorder is an adult. The chances are pretty good.

Among the few variables predictive of long-term adjustment, Robbins at the time said that greater improvement occurred in people over 40 years at the time of follow-up.

So age is somehow a critical factor, which is a strong indication that antisocial personality disorder, let alone psychopathy, are somehow bodily issues.

They may not be psychological at all. It may not be a psychological problem, but a medical problem.

The same way today we consider depression, psychotic disorders, schizophrenia, bipolar disorder as essentially medical conditions.

I have no idea why they still find their place in the DSM, except for money and insurance.

So there's other data by Black and others.

It shows that men with ASPD improved with increasing age.

Another variable, by the way, is prison, incarceration.

Fans found that men incarcerated for less than a year had a higher rate of remission than men who were never incarcerated.

And men who were incarcerated, spent time in prison, big time for less than a year, had a higher rate of remission than men who were incarcerated for longer than a year, since the year is a crucial critical factor.

So these findings suggest that a brief incarceration acts as a deterrent to antisocial behavior, but a limited time deterrent. It wears off, memory somehow evaporates, and the deterrence is gone.

But if you spend a longer period of time in prison, this deterrence lasts and could be even lifelong.

Prison does reform.

Even if there's no rehabilitation, the very act and fact of limiting freedom seems to have a curative effect, seems to have a curing effect, a healing effect, or a remitting effect at least, when it comes to antisocial personality disorder, psychopathy.

Actually prison has adverse outcomes in borderline personality disorder.

And to some extent in narcissistic personality disorder.

But with psychopaths, psychopaths it works, especially as they grow older.

What about relationships?

Marriage is a moderating variable, believe it or not.

Married psychopaths are much less antisocial.

But it's a chicken and egg situation.

Maybe psychopaths who are less psychopathic simply get married.

Marriage is a social institution. It's a ritual, it's a ceremony, it's a procedure.

And psychopaths hate all these things. They're nonconformists, they're rebellious, they're defiant and contumacious.

So maybe the more psychopathic you are, the less likely you are to get married.

And so it's not that the marriage affected the antisocial behavior, it's that if the antisocial behavior is low-level, low-key, you're more likely to get married.

Possibility, I'm not sure.

Just delineating the possibilities.

But it's a fact that being married is positively and highly correlated with a reduced incidence and severity of antisocial behavior.

Robinson's study, over one-half of married people with ASPD improved, but very few unmarried people, spouses, partners, other people close to the ASPD.

They play an important role in regulating the ASPD, urging therapy, and the improvement often comes when one has a source of personal support, motivation.

Sometimes just not wanting to hurt the other is sufficient motivation to not engage in antisocial behavior.

People with ASPD who were admitted, they had stronger family types. They were more involved in their communities and they were more likely to live with their spouses.

These findings are largely consistent with the Glucks findings, which linked job stability and marital attachment with improvement.

Each of these situations, from brief incarceration to relative success with marriage and family life, could easily be the result of improvement rather than the cause of improvement, as I just said.

So we can expect people with ASPD who stay happily married or didn't face a lengthy period of incarceration to have probably had a milder case of ASPD to start with.

Maybe they were predisposed to getting better somehow.

You see, even psychopaths are embedded in culture and society and maybe their upbringing or their education or a chance opportunity.

It's very difficult to tell the chicken from the egg.

There is some evidence regarding marriage.

So there was a study of male twins and it followed them from 17 to 29 years.

The researchers discovered that men with less severe faults of antisocial behavior, these men were more likely to marry than the more antisocial twins.

So there was one twin who had ASPD, but it was less severe than the twins ASPD.

And so the one with a less severe form got married.

And so severe antisocial symptoms hinder marriage because they interfere with forming intimate relationships, psychopaths.

Don't do intimacy. Can't do intimacy.

Another factor that moderates eventual outcomes is the degree of childhood socialization, the child's tendency to form relationships, the child's proclivity to internalize social norms, whether the socialization process was disrupted.

Jenkins and Glickman identified two types of children with conduct disorder, socialized children and the under socialized children.

Glickman said that the ability to develop group loyalty, group loyalty is crucial. It marks fundamental division between the socialized and the under socialized children in the conduct disorder group.

Socialized children, regardless of their wayward behavior, naughty behavior, socialized children form strong ties to a familiar group of friends.

Under socialized children tend to be loners.

In a 10 year follow up, Henn and his colleagues found that socialized delinquents were less likely to have been convicted of crimes or imprisoned as adults.

Under socialized children, under socialized delinquents went on to a life of crime and imprisonment.

There are quite a few studies about psychopaths. It's a fault-bought topic similar to narcissism.

Three additional studies that I may just mention is the follow up studies of Maddox, Gibbons and the partners and the work done by Tonk. All these were conducted in the United Kingdom in the 1960s.

The subjects of the studies were considered psychopaths, which is today the rough equivalent of ASPD.

Maddox reported a five year follow up study of patients seen in an outpatient department between 1961 and 1963.

The men were considered psychopaths and the inclusion criteria included impassivity, trouble with the law, several spouses of sexual partners, trouble at school and unreliability.

Maddox traced 52 of the 59 men. Ten of them, 19% have settled down, 39, 75% have not settled down and had not settled down and 3% and 3 of them, I'm sorry, 6% died by suicide.

That's not very far from borderline by the way.

Corresponding number for borderline is 10%, 10 to 11.

But what does it mean to settle down in the 1960s?

Maddox defines settling down as having shown a reduction of impulsiveness, enabling the patient to stay in the same job, stay with the same partner and generally a reduction in symptoms that placed him in the category in the first place.

It's a good enough definition even today.

Was no clear distinction between the men who had settled and those who had not, but 15 of them, 38% of those who had not settled, drank excessively or were frank on callings.

And his associates reported on an eight year follow up of 72 incarcerated criminal psychopaths whose courses, life development, autobiographies were compared with those of 59 ordinary criminals.

So 72 psychopathic criminals, 59 non psychopathic criminals.

The psychopaths were considered as having severe cases and they were selected with the assistance of experienced prison medical officers.

The psychopaths had a greater number of subsequent convictions than the controlling subjects and yet 24% of them had only one or no conviction.

The psychopaths were more likely than the control subjects to have a normal EEG that is true to this very day.

Americans concluded that psychopathic personality, as he said, I'm quoting, "does not inevitably portend as hopeless prognosis as is usually implied."

He was malignant optimist.

Psychopaths considered aggressive had a worse prognosis.

Violence externalized aggression, externalization.

This is the extreme form of psychopath.

And it's compared to what we call the inadequate psychopath.

So aggressive psychopaths externalizing psychopaths had more convictions, were committed for aggressive offenses, willful damage, drunken assault, etc.

Gibbons wrote, "It seems probable that the aggressive psychopath is so crippled in all his social relations that he is only able to live by crime and his record therefore consists very largely of acquisitive offenses."

Paul reported also on outcomes in criminal psychopaths.

These criminal psychopaths have been legally classified as psychopaths in the United Kingdom and they were incarcerated between 1954 and 1961, the year I was born, at Rampton Hospital.

It's a special, close security psychiatric hospital that at the time catered to offenders considered dangerous or had violent propensities.

Pong defined psychopathic behavior in a bit of a special way.

I'm quoting.

Psychopathic behavior, he defined it as "criminal behavior characterized by extreme callousness, brutality, disregard for others on the one hand, and/or criminal behavior, which is not necessarily violent or serious, but is repeated over and over again, recidivism.

The men in his study were aged, they had a mean age of 29, had followed up, and they had been incarcerated nearly nine years by that time.

Among the 587 men, 171, 29%, relapsed.

Pong concluded that the prognosis is far from hopeless because only 29 relapsed.

The few that were admitted at much later ages, they did not relapse.

So, late age, at the moment of incarceration, predicts good outcomes.

No relapse and no recidivism.

And as Pong said, both age of discharge and length of stay in hospital correlated positively with success.

But findings are similar to blacks in their follow-up study.

So we have no reason to doubt them.

Okay, that's the overview.

What are my conclusions?

What am I trying to tell you?

Antisocial personality disorder is a childhood disorder.

It's behavioral.

It's defined by society and for society.

It's very well studied.

Possibly it's the most well studied disorder.

It started 150 years ago, at least.

Definitely in the past 80 years or even 100 years, it was a linchpin of mainstream psychological research and we have a lot of data on psychopathy, or people with antisocial personality disorder.

It's a chronic disorder.

It begins in early childhood, continues through adulthood.

It's associated with other mental health and addictive disorders.

Mortality rates are very high.

People with ASPD improve with age.

The problems continue, even though they improve.

But they continue on a lesser scale and they are more benign and the target group is much smaller.

So poor job performance, domestic problems, abuse.

The improvement can occur at any age, but most likely between the mid-30s and the mid-40s.

People with more severe symptoms at onset appear to be the ones with the most severe antisocial personality disorder at follow-up.

There's no way to predict outcomes in ASPD, but people with earlier onset tend to have a worse outcome and moderating factors include marriage, family and community types, early incarceration, adjudication in childhood, the length of incarceration, degree of socialization.

There's a lot of work to be done first and foremost to determine whether we should establish a whole class of social relational mental disorders.

Narcissism, for example, is a relational disorder.

Psychopathy and antisocial personality disorder, these are societal disorders.

It's not shameful to say it's a group of disorders which have to do with brain abnormalities, for example, bipolar, psychosis, schizophrenia.

There's a group of disorders which are innate and reflect mental illness.

And there is a group of disorders which erupt and occur only when other people are present, only in interpersonal and societal settings. These group of mental illnesses should be separated, even in the DSM, under the heading of societal, cultural and interpersonal relational mental health disorders.

Until about 100 years ago, this was the case.

Many mental health disorders were described as character disorders.

We need to determine the full extent of this alleged disorder in various subpopulations, for example. We need to determine the clinical picture in women, for example. Of course, outcome, we don't know any of this.

There's a small percentage of people with ASPD that have no precursor, have no history of conduct disorder.

How come?

We need to characterize this subset. We need to use much bigger samples.

We say that the disorder is chronic, but why? Why do some people improve while others do not, even though we know the predictors, we don't know the process. We don't know if therapeutic interventions, for example, incarceration, how do they change the course of ASPD, if at all? Outcome predictors are important, of course. Clinical illness variables, potential biomarkers, everything, yeah, sure.

But if this is a disorder of childhood, we must focus on troubled children. They are at the greatest risk of developing ASPD.

And children go through the process of socialization. They are in the throes of becoming.

So these are disorders of becoming. Something goes awry in transitioning from tabula rasa to individual. Everything again is not as it should be in the process of individuation.

We need to focus on this. We don't need to pay so much attention to criminals in prison populations. There was a wrong orientation. It led us astray. We wasted decades.

Of course, some people got rich in the process. Names withheld. But it led us astray.

We need to realize that disorders like ASPD reflect a child's inability to internalize socialization. And a child is unable to internalize society and its signals and messages and values and core and conventions and mores.

Child is unable to internalize all these.

Because there's something wrong with the socialization agents. His parents, his peers, his teachers, his role models. Something's wrong with them. Something goes awry.

The acculturation and socialization processes in these children, they just don't learn how to be social beings.

It's not so much as antisocial personality disorder. It's like non-social personality disorder. These children become adults who go through life doing whatever the hell they want.

Because they don't realize the interplay between society and individual.

This is what we need to focus on.

Not on measuring all kinds of nonsense in prison populations or people hospitalized in mental asthma. We won't get anywhere with this.

Because these people are finished. They're ready made. They're made.

They're not going to reverse. They're not going to regress. They're not going to change.

So why study the unfortunate outcomes and not the process that leads to the outcomes and give us hope of treatment?

And yes, of course there is hope of treatment if we care to find out what causes this disorder.

Including the possibility that there are brain abnormalities and so on.

Again, it's a chicken and egg.

Was the brain abnormality caused by the disruptive, disrupted process of socialization? Or did it cause the disrupted process?

I opt for the first.

I think the brain abnormality is a secondary, not primary.

But this also needs to be proved, or at least investigated.

We have a lot of work to do. Eight years later. Shame on us.

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