What do serial murderers, hardened criminals, and punitive dictators have in common with ruthless business executives who profit from the misfortunes of failed investments or downsizing? In his latest book, "The Psychopath Test," journalist Jon Ronson convincingly presents the argument that many share qualities that produce a high score on the Hare Psychopathy Checklist-Revised (PCL-R) including these core traits: lack of remorse for destructive acts, inability to experience empathy, impulsiveness, sexual promiscuity, and manipulativeness. At the same time, however, Ronson raises important and timely questions about the psychiatric enterprise and the possible over-diagnosis of ordinary human traits.
The PCL-R is a research instrument with stellar psychometric qualities. Robert Hare, the Canadian researcher who developed the scale, was one of the first psychologists to draw attention to the core personality traits of what, in the past, was referred to as "sociopathy." Now listed as a diagnosis in the American Psychiatric Association's reference manual, the DSM-IV-TR, it is called "Antisocial Personality Disorder." Having one or two of the qualities that give a person a high score on the PCL-R doesn't mean that you're a psychopath, and it's possible to accumulate a high score without ever having committed acts that have seriously harmed anyone. As with any psychologist instrument, there is a certain amount of error involved.
Unlike typical self-report rating scales the PCL-R, to be valid, must be given by a person trained in its administration and scoring. Hare travels around the world giving training seminars (at a fee) which allows even non-psychologists to become certified. The tool is clearly most valuable to people who work in the criminal justice system, but if you believe Ronson, it might be of use for Human Resource managers or financial analysts.
Ronson's explorations through the world of psychopathy research also led him to insights about flaws in the diagnostic systems that psychiatry uses to decide who's a psychopath and who's not. I think the most compelling material in the book aside from the book's main thesis is the analysis Ronson provides about the DSM itself. In a previous post, I pointed out the problems in the DSM5's proposed changes in diagnostic criteria for Alzheimer's disease. Ronson takes on the autism diagnosis on similar grounds- are diagnoses expanded upon not for scientific or even clinical reasons but in order to sell more drugs?
Just as we are over-medicating older adults with dementia (who may or may not have Alzheimer's disease), are we over-medicating children based on the expanded diagnoses of not only autism but bipolar disorder? Fellow Psychology Today blogger Allen Frances, M.D., expresses his doubts, in an interview with Ronson, about whether the diagnostic pendulum has swung too far in the direction of creating and expanding diagnoses to apply to behaviors within the range of "normality."
These arguments are not meant to imply that we should discount the impact on people's lives of the symptoms associated with psychological disorders. Nor should we discount the true suffering that can be caused by people high in psychopathy who commit murder, felonies, or con jobs. The point is that over-medication on the basis of over-diagnosis can itself create symptoms that only make the individual's life more challenging on a daily basis.
Returning to the issue of psychopathy, it's doubtful that a medication will be found to "cure" this collection of personality traits. Yes, there is research suggesting that psychopaths have smaller amygdalas than non-psychopaths. This is important because the amygdala plays a role in emotional learning. If people don't learn to fear the consequences of their negative (if not criminal) behaviors, then what's to stop them from committing those behaviors?
However, can the behavior of anyone, including someone with a presumed brain anomaly, be reduced to the size of a brain structure? Is it possible that there are loads of people with small amygdalas who don't become murderers because their early environments made up for whatever neurological deficit they were born with? Or did their amygdalas develop abnormally because of harsh early lives? Even experiments on lab animals can never answer these questions. Though one could imagine a homicidal Mickey Mouse, since mice don't have prefrontal cortexes that control their ability to plan, reason, and think abstractly, it's pretty tough to generalize from controlled experiments involving non-human species.
It's rare to read a popular book about psychology by non-psychologists that causes me to want to stand up and cheer. However, with "The Psychopath Test," I found myself more than once not only cheering but laughing out loud. You may not become an expert at sniffing out psychopaths but you'll learn a great deal about the ambiguities and pitfalls of psychiatric diagnoses. Human behavior doesn't neatly fall into the categories of "medical" illnesses. A broken bone is one thing; a broken mind something else entirely.
To sum up, here are the main points from "The Psychopath Test":
1. People high in psychopathy aren't necessarily found in prison. There are plenty of individuals who have psychopathic traits, from the lover who unceremoniously dumped you to the boss who seemed to take pleasure on firing you.
2. Psychopaths are people too. Though Robert Hare regards psychopaths as a "different species," the point that they may have become that way through their early experiences such as abuse or neglect is a valid one.
3. Don't be too quick to jump on the diagnosis bandwagon. The precipitous rise in certain psychiatric diagnoses (autism, childhood bipolar diagnosis, Alzheimer's disease) may say as much about the politics of psychiatry as about its science. Erroneous diagnoses can have disastrous effects.
4. Appreciate the fact that psychological disorders rest on a continuum. Unlike physical illnesses, the disorders that affect the mind can't easily be categorized. Not only do people vary in degree, but what's normal in one culture may be evidence of disorders in other cultures-there are few absolutes in this field.
5. Learn to differentiate good from bad self-rating scales. The PCL-R is a good rating scale that is based on years of solid research. Unlike checklists you find in magazines, those that researcher use must meet rigorous scientific criteria.
The field of abnormal psychology is full of danger zones in which erroneous diagnoses may be too loosely applied or serious diagnoses missed. There's an art and a science to the process. We can only hope that the science of validly determining the true nature of disorders continues to help alleviate the anguish they can cause.
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Copyright Susan Krauss Whitbourne, Ph.D. 2011