The Personality Disorder We Don't Hear Enough About

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It's no news that some pathological personalities have a sadistic quality about them. Narcissists will torture with put-downs to keep their ego afloat; antisocial personalities may make people suffer into submission to get a need met, enjoying the sense of power it provides them. However, the aforementioned are not usually openly hostile and destructive as a general way of relating to others. In these circumstances, such acts of cruelty are really means to an end; a part of the disorder. Is there a personality style where hellish cruelty is a central component?

The Sadistic Personality

While no longer addressed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), sadistic personality disorder (SPD), similar to the passive-agressive and masochistic personality, has continued to be recognized as a legitimate condition by many (e.g., Millon, 2011; Plouffe, Sakloske &Smith, 2017; Coolidge et al., 2018; Kowalski et al., 2019). Sadistic personality qualities have also been resurfacing as a hot topic in the realm of the dark triad/tetrad.

First written about as a psychological construct by Krafft-Ebbing in the mid-1800s (Millon, 2011), the sadistic character was then recognized as someone who enjoys instigation of pain, cruelty, and humiliation as sexual dominance. This was expounded upon by Freud, who discussed sadism and masochism as "bipolar dimensions of the aggressive component of the sexual instinct" (Millon, 2011).

Looking beyond this sexual basis, however, Eric Fromm later posited that sexual sadism was only one expression of some people's need to humiliate. Millon (2011) quoted Fromm:

"Mental cruelty, the wish to humilate and to hurt another person's feelings, is probably even more widespread than physical sadism. This type of sadistic attack is much safer to the sadist... the psychological pain can be as intense or even more so than the physical... the core of sadism...is the passion to have absolute and unrestricted control over a living being. To force someone to endure pain or humiliation without being able to defend oneself is one of the manifestations of absolute control..."

In other words, it seemed that some people's interpersonal style is entirely constructed around sadistic behavior. It was just this line of thinking that led to SPD being included in the DSM-3 Revised edition (DSM 3-R [1987]). However, this was limited to the "Proposed Diagnostic Categories Needing Further Study" appendix, and never made it further, despite over 50% of forensic psychiatrists surveyed at that time reporting having interviewed cases that would meet criteria (Levesque, 2014). According to Millon (2011), disregarding it in future editions was a political decision, but a foolish one, given it is clear there exists an aggression-loving population in society that markedly contributes to the decline of civility.

Sadistic Personality Disorder Criteria

Criteria for the condition was listed in the DSM 3-R as a pervasive pattern of at least four of the following, which had emerged by adolescence:

• Use of physical cruelty or violence in relationships to establish dominance (not simply for the sake of secondary gain, like robbery).
• Humiliates/demeans people in the presence of others.
• Unusually harsh treatment/discipline towards someone under their control.
• Amusement from witnessing the psychological/physical pain of others, including animals.
• Has lied to harm/inflict pain on others.
• Operates through intimidation or terror to get others to comply.
• Restricts the autonomy of people they are close to (i.e., spouse must always be accompanied, children aren't allowed out of the home).
• Fascination with violence, weapons, and torture/injury.

Millon (2011) furthered that those with SPD tend to be noticeably abrasive with sarcasm, criticism, and hostility. Interestingly, some can make this seem an appropriate quality if they are in the right career, such as the relentless drill sergeant. They also tend to be strongly opinionated and unwilling to consider others' views, and may harbor an eruptive temper.

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This latter component is especially important, as those with SPD cannot handle vulnerability. Therefore, at the first sign of a threat, no matter how insignificant, their preferred tactic is "offense is the best defense" to show they're not to be played with.

Although SPD is no longer included in the DSM, it can still be diagnosed using the Unspecified Personality Disorder category, as follows: Unspecified Personality Disorder, Sadistic.

The Development of SPD

While research is scant on SPD etiology, there is some evidence there is a large learned component, including social imitation. Some of those studied with SPD have a history correlating to regular exposure to sadistic activity on TV, in video games, movies, and violent rap music (Pallone in Schlesinger, 2007).

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Further, Millon (2011) noted that people with SPD are often targets of anger and are deprecated by caregivers. He hypothesized, interestingly, that these children actually feel empowered by the negative treatment. This is because the negative attitudes projected towards them are interpreted as, "I have the ability to influence the moods, attitudes, and behaviors of others," and each such interaction encourages an image of influence/potency. Millon finished, "Their perception of themselves as possessing the power of causing trouble spurred these children on to more vigorous action and counter-hostility."

Given the effectiveness of this tactic in the nuclear family, it makes sense it becomes globalized as they enter the world, and they go through life indiscriminately discharging the hostility they hold towards their early caregivers.

Like other personality disorders, there is also believed to be some level of trait-based components, such as a propensity for poor impulse control and anger, that meld to create the perfect storm of SPD.

Differentiation from Antisocial Personality Disorder

It bears repeating that violence, torture, exploitation, lying, and anger in SPD are borne of the pleasure of both witnessing anguish in others and the control that it provides. As noted in Kowalski et al. (2019) this is in contrast to APD where such actions are engaged in for secondary gain/to feed the id (i.e., enjoyment of dominance for obtaining sex, as in rape; lying to cover up or manipulate people into providing what they need; harming someone to rob them or keep them from talking).

Given the chief feature of APD is disregard for, and violation of, the rules of society and the rights of others, it is easy to see that SPD is rather proximal and in fact the two are known to co-occur (Millon, 2011). Others, such as Murphy and Vess (2003), suggest that it may be best to consider SPD a subtype of psychopathy (APD), whereby the psychopathic person, unlike most of those with the condition, both recognizes and pays attention to the suffering of others. In short, the sociopathic behavior is borne of the need to create suffering in others.

An example that many readers may be familiar with is Dennis Rader, otherwise known as Bind, Torture, Kill ("BTK"). Though formally diagnosed as APD, he may be a prime example of the mingling waters of APD and SPD. This is because his style of psychopathy seemed very much influenced by his enjoyment of torture.

Treatment Implications

As noted in many other posts (e.g., Depression or Depressive Personality, OCD or OC Personality), a lot of conditions can seem quite similar, but that does not mean they are addressed similarly. Here, while SPD and APD may, at first glance, appear similar, readers have learned they're quite different, particularly in what drives the behavior. Therein exists the importance of accurate differential diagnosis and that it is not enough to simply identify and treat symptoms. Though many conditions share symptoms, accurate diagnosis allows us to conceptualize the nature of the symptoms and thus understand their purpose/etiology, which drives proper treatment.

APD is largely considered an untreatable condition, given a profound inability to understand feelings and therefore inability to empathize, and the fact that those with APD feel entirely justified in any behavior, and their tendency for lies and deceit would make meaningful discourse difficult (Yudofsky, 2005). Understandably, many practitioners are trained to quickly write off anyone who presents with APD and therefore may not invest wholeheartedly in attempting to care for them.

SPD, on the other hand, while ostensibly antisocial, can be more malleable. This is because they are able to understand feelings, evident in the fact they know others are suffering. Thus, with a patient practitioner, they sometimes are able to learn to empathize and therefore more effectively relate, which carries the possibility of salvage.

Considering the aforementioned evidence of strong learned components, as has been proven regularly through cognitive therapies, if something is learned it can be unlearned if a person is somehow motivated and in the hands of a skilled therapist.

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As one can imagine, therapy may be rather difficult with SPD given their need to be in control. Having someone working towards changing you is the ultimate lack of control. One chink in the armor is that many people with personality disorders don’t enter treatment to change their character, but rather come in to address depression, anxiety, relationship matters. Therefore, if a therapist can cultivate insight that the person's interpersonal style is a root of their presenting complaint, a foot is in the door, and productive therapy towards curbing the SPD could gain traction.

Once in, it’s important to explore the idea that their solution to vulnerability—an abrasive and hostile style—merely creates self-fulfilling prophecies. While some will submit to their actions, others will resist and attack back, strengthening the SPD's will to keep up the hostility, creating a perfect circular storm.

Considering the above, should a therapist find themselves working with someone with SPD, it would be wise to seek consultation if they are not familiar with hostile/abrasive individuals. It is a delicate dance of being understanding but now allowing the patient to believe they've intimidated you into being their ally, coupled with an ability to show the patient someone can be strong towards them, but remain fair and respectful. Through this relational dynamic, it is hoped a strong therapeutic alliance can be formed whereby the patient may come to imitate the more adaptive interpersonal ways of the therapist, but be receptive to some level of vulnerability that will allow exploration, and reconstruction of, their maladaptive core schema.

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