What Was a Constitutional Psychopath?

Source: Gwendolyn Murray, used with permission

A student recently shared that in 1911, her relative was institutionally discharged with a diagnosis of Constitutional Psychopath. She wondered if it meant her ancestor was a socially corrupt, morally depraved individual, like what we call psychopaths today.

Not likely.

The usual definitions

To the uninitiated, "psychopath" is likely not reserved for someone with a debased relationship to society, as those in the psychology field know it.

Many readers have likely encountered "psychopath" or "psycho" being used as a catch-all for people acting in some psychologically-puzzling manner. This could range from the vexing behaviors of someone with severe OCD to Cluster B personality disorders. It's as if the prefix "psycho" is simply pop-culture shorthand indicating the observance of something psychologically askew.

In my classes and trainings, students often wonder how psychopath differs from sociopathy, the latter tending to be associated with antisocial personality disorder (APD). A raised hand often leads to, "Aren't they all the same?" Ostensibly, yes, but let's look at the nuance as it's accepted in the field.

APD, sociopath, and psychopath are a matter of synonym and degree. Antisocial personality disorder is just a modern term for sociopath (e.g., Millon, 2011; Shannon, 2019) in that it was thought to be more descriptive of the interactive style. In short, "antisocial" has nothing to do with social inhibitions like in social anxiety disorder; it means they do things in a fashion grossly against societal norms, usually in a marked morally bereft fashion, in order to meet their needs.

Psychopaths, on the other hand, don't just disregard and violate the rules of society and the rights of others. What they do is egregious and beyond disregard, it is entirely without conscience. "Without conscience" so aptly describes the condition that Robert Hare, Ph.D. (1999), used this as the title of his comprehensive book on the subject.

Johnson (2019) nicely discusses the psychopathic nuances by painting a picture of psychopaths as more predatory, emotionally desensitized, calculating, and conniving; there is a marked effrontery to the "normal" antisocial activity. He explained that those on the psychopathic end of the spectrum are thought to be born with abnormal brain development, influencing the severity of their personality problems.

It may help to illustrate that your garden variety thug or murderer would more likely be in the APD realm; Saddam Hussein, Jeffrey Dahmer, Eileen Wournos, and BTK would easily meet APD criteria, but in a much more malicious manner, earning them the category of psychopath.

Before psychopathy as we know it

APD/psychopaths as we now understand them have existed since time immemorial. From the biblical Cain to Vlad the Impaler, the latter impaling people and then putting them on display outside his castle to watch them suffer (Markarian, 2020), society has dealt with severely morally-defunct characters.

In their respective eras, such people were probably most frequently referred to as some derivative of "evil," though an ancient Greek, Theophrastus, categorized them as "the unscrupulous" in recognition of the pathological lack of empathy (Kiehl & Hoffman, 2011). Closer to our times, Pinel, in 1801, wrote that some patients had "insanity without delirium" (Millon, et al., 1998). By this, he meant they were impulsive and self-damaging with intact reasoning abilities; in short, this illustrates the calculated, negative behaviors without regard for consequence that psychopaths exhibit. Millon furthered that this conceptualization went on to be termed "moral insanity" given the value-laden bent of psychiatry at the time.

"Psychopath" wasn't always synonymous with social scourge

According to Kiehl & Hoffman (2011), the word psychopath didn't enter the scene until 1888 when the German psychiatrist J.L.A. Koch used the term psychopastiche, literally meaning "suffering of the soul." Surely, this was the root of "psychopathology" as in the examination of psychological sufferings/diagnoses, like the course some readers took in graduate school.

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Soon, as pointed out by Millon (2011), a shorter version, "psychopath," became popular. It was a generalized term of the era for any "persistent styles of abnormal functioning ... of an ostensive organic nature." Essentially, it was a catch-all term for psychological pathology/behaviors so omnipresent they were assumed to have genetic/congenital roots. "Psychopath" had yet to be considered synonymous with unconscionable activity.

This was, however, the dawn of the study of psychopathology as we know it. Koch soon began to recognize nuances amongst the psychopastiche, and it could be argued that this led to opening the gates of personality disorder study.

Taking a step closer to our modern understanding of the term, in 1891 Koch, beginning to expand from the general "psychopath," suggested that "moral insanity" be replaced with "psychopathic inferiority." Koch preferred "inferior" as it indicated the personalities deviated unfavorably from the norm (Millon, 2011).

Source: Stux/Pixabay

Have we come full circle in understanding the causes of psychopathy?

Given the proximity of Koch's use of the terms "constitutional" and "inferiority," one could also hypothesize that though he didn't write it, "inferior" to Koch indicated some arrested component of brain development that encouraged those afflicted to never expand from the pure id state they were born with. Thus, they weren't able to assimilate to acceptable social mores and behaviors and, though he couldn't prove it at the time, Koch was perhaps precocious in his belief that there were significant neurodevelopmental components contributing to this morally depraved state, much as Johnson discussed evidence for in 2019.

Researchers (e.g., DeBrito et al., 2021; Tully et al., 2021) continue to inform us of the increasing evidence of significant neurodevelopmental underpinnings of psychopathy. DeBrito (2021) documented that structural and functional brain abnormalities in, for example, the prefrontal cortex and amygdala contribute heavily to "disruption in emotional responsiveness, reinforcement-based decision-making and attention," which are characteristic of psychopathy.

Modern conceptualization of "psychopathy" and importance of subtypes

Though our modern idea of APD/psychopathy was included in the term psychopathic inferior, Millon (2011) was quick to note that, upon closer look, this was only a small portion of what Koch had in mind. He included numerous subtypes, some marked less by significant moral depravity than by high sensitivity, eccentricities, and impulsive fury.

It's interesting to consider that these composite states Koch noticed were primitive recognitions of what we now call mixed personality disorders, as written about in "Can a Person Have More than One Personality Disorder?" It is not unheard of, for example, that the eccentric paranoid or schizotypal personalities have an antisocial streak, as illustrated, for example, in Yudofsky (2005).

Eventually, the "inferiority" term did not sit well due to its belittling intonation (Millon, 2011), and, in America, "constitutional psychopathic state" and "psychopathic personality" became the preferred term for what we would now pointedly refer to as a psychopath. Provided the fascination with understanding this "insane/non-insane" disposition (Hulbert, 1939), differentiating and dissecting psychopathic (as we know it) presentations persisted.

In the 21st century, Millon (2011) listed seven distinct subtypes, including not only the more traditional malevolent sort but an adventurous type he called the "disaffected aggrandizing subtype." This would align with what early on was called a Haltlose personality, a morally-devious modus operandi superimposed on a hypomanic personality. In short, a personality in regular need of new stimulation, impulsivity, and drifting in their antisocial pursuits to please themselves.

Source: Geralt/Pixabay

More recently, much like Koch, researchers continue to express interest in the utility of psychopathy subtypes. For example, Hicks and Drislane (2018) noted, "subtypes can help to inform the understanding of psychopathy and antisocial deviance more generally." This obviously can help with matters such as profiling, public safety, and further research on developing interventions, and, perhaps, eventually, even prevention, of psychopathic behavior.

All things considered

Ironically, it seems that the more it was attempted to neatly compartmentalize personality pathology into super-distinct disorders, the more evidence mounted for understanding them as more multifaceted and nebulous, leading to alternative conceptualization proposals (e.g., APA, 2013; Hopwood et al., 2018).

At the heart of these alternative proposals is understanding personality pathology in a more dimensional or trait-domain manner. Rather than taking note of defining symptoms of, say, Histrionic personality disorder, and leaving it at that, a dimensional or trait lens could encourage observation for clinically-relevant things that might be missed if a clinician is trying to neatly categorize the patient's diagnosis. A prime example is someone with marked histrionic characteristics who, upon closer examination, has strong dependency needs, as written about in "Why Some Adults May Still Have an Infantile Personality." Clearly, there can be treatment implications to nuance.

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from an individual's provider or formal supervision if you’re a practitioner or student.