Is Psychopathy a Mental Illness?

It’s hard to believe that I haven’t covered this topic in over 500 posts up to the point.  It is a question that I receive from time to time and a question that many neurotypicals have staunch opinions on.  Is psychopathy a mental illness, or is it – as some would say – merely a defect in personality or character?  To answer this we must consider the types of mental illness as well as the role neurology plays in personality.  I hope that it is clear to the reader that the answer to this question should be ‘yes.’

Consider depression.  Depression can be organic – that is, caused by neurotransmitter imbalances in the brain – or environmental.  We do not make a distinction between these types of depression except via the approach we can treat them.  For the organically depressed, psychotropics are often panacea.  For the environmentally depressed, psychotherapy is often the cure.  We don’t call one type of depression “real” and the other “fake” – at least I hope not.  That is, we treat conditions born of neurology and of environment the same … except when we don’t.

Psychopathy has well-proven neurological roots.  The structures governing impulsivity, aggression, and empathy (among other areas) behave differently in psychopaths than neurotypicals.  Hell, they even are different than those found in “vanilla” ASPD individuals.  I leave the proof of this up to the reader – check the books The Psychopath Inside and The Psychopath Whisperer for further information.  However, it is also known that psychopathy (which ignores etiology) can arise from environmental factors including a troublesome childhood or forms of abuse.  How can something be a character defect (implying choice) if it is hardwired?  If we take the approach that we did in our treatment of depression, we would easily conclude that psychopathy is a mental illness regardless of its origin.  I should note that I believe this holds regardless of whether the afflicted believe themselves unwell or not.  Objectively, most psychopaths suffer some drawback due to the condition even if it may not be constant in nature.

Is psychopathy a mental illness?  Absolutely.  Those that believe otherwise are merely subscribing to theories that dehumanize the psychopath.  By painting a picture of choice, they put the onus on the psychopath to prove that they are not defective.  We psychopaths certainly have choice in our actions, but I am not so convinced that we have choice in our proclivities.  Either way, we should reject the notion that psychopathy is a mere defect in personality or character.  It goes much deeper.

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Comments

    • Anonymous says

      If I were given the option to start a completely new life as an NT, I probably wouldn’t take it. But the thought does seem appealing at times. Being a psychopath, at least for me, is an incredibly boring and empty life. I will never know what it’s like to “feel”. The closest thing I have to emotions is a seemingly insatiable desire for reckless violence and destruction. And I’ve built up an entire life based around restraining it, the only “real” thing about me. Plus, putting on a mask and being “pro social” is absolutely exhausting, and it gets very dull at times. Also, my impulsiveness will absolutely be the death of me. I’ve pretty much run my body into the dirt, and my arm is all kinds of screwed up. I don’t mean to sound like I’m complaining though. Being able to look back on the violent, bloody mess that is was my childhood and genuinely say that I don’t give a shit is a beautiful thing. And being a psychopath definitely has some rather unique perks. But I do wonder what it would be like to be a completely normal NT, in spite of my usual contempt for them. If nothing else I would probably be less bored.

      -A

      • Jessica Kelly says

        It’s interesting. I would like to know what I’m missing out on, but I have no conviction to give up what I am in the process. I know no other way.

      • says

        You’re not missing much. I’m NT and I don’t have feelings either. I can feel angry, frustrated, irritated etc but only in extreme circumstances. I’m usually very calm and never feel negative emotions like being sad, confused, nervous etc. Personally, I can’t see a reason to want to feel things when feelings are of no importance and can often get in the way of the moves you need to make. NTs might not feel stuff as much as we claim to, except drama queens, who are basically overprotected/socialised into getting upset over nothing.

        • Scarlet says

          Forgive me, but how does being NT and having no feels work? Doesn’t having little feeling by definition make you neuroatypical? Not implying in any way that’s a bad thing.

          • Anonymous says

            The word neurotypical has been used in many ways to describe people who do not have certain disorders. If we go by that definition, then, if she’s not diagnosed with autism, ASD, ASPD, psychopathy, BPD, NPD, or bipolar disorder, schizophrenia, etc. then she’s neurotypical (but not an “empath”)

          • Jessica Kelly says

            That may very well be. Around here we tend to use the term ‘NT / neurotypical’ as a weasel-word to mean not antisocial given the equal problems that the term “empath” has. The human condition is quite diverse though, so bits and pieces of anything can be found in nearly everyone.

          • Jessica Kelly says

            It’s a weasel word, ‘neurotypical’, that means not ASPD and not psychopathic.

    • Well-Wisher says

      Psychopathy is generally considered a (though not present in the DSM as itself) personality disorder, a class of mental illnesses of which one of the characteristics is a tendency for ‘ego-syntonicity’. What this means is that the symptoms of the disorder tend to correspond to the worldview of the afflicted, which as a result they consider that there is nothing wrong with themselves, as they view their abnormalities to be a normal part of their character and justified responses to their circumstances. Personality disorders are disorders that run so deep that the core character, and consequently the perspectives, opinions, and behavior of the afflicted are warped.

      In the psychiatric field, this makes them unlikely to seek treatment in the first place as they do not think that anything is wrong with them. Even when they are in a treatment setting, this makes them uncooperative in therapy, complicating the treatment of these disorders, especially personality disorders, which are already very difficult to treat in the first place (psychotherapy is not so effective for treating personality disorders). This is what makes Borderline Personality Disorder is so prominent among personality disorders (google “personality disorder”; about half of the search results are for BPD); because the afflicted sometimes seek help.

      This ego-syntonicity is prominently displayed in ASPD and psychopathy, as the afflicted see their antisocial behavior as justified, and even when they know that something is “off” about them compared to the general population, they do not believe that their worldview and behavior is wrong and view prosocial character as weak. They respond very poorly to therapy, being uncooperative or only superficially cooperative, and usually do not seek it in the first place, and the therapists that attempt to treat them have to be wary when interacting with them to guard against manipulation.

      It is unsurprising that a psychopath wouldn’t choose to be different if the disorder was just a choice.

      After all, mental illnesses rarely involve choice, a fact that is so hard to swallow for many people.

  1. MA32 says

    «They respond very poorly to therapy, being uncooperative or only superficially cooperative, and usually do not seek it in the first place, and the therapists that attempt to treat them have to be wary when interacting with them to guard against manipulation.»
    The last part is always true. But the first isn’t. Sometimes they respond pretty well. If you take the time to read through the blog until the last text, and if possible the book about her earlier experiences, you’ll see the progression.

  2. MA32 says

    For instance, the last text was written in a complicated time for her, but you can still see that she wants to be better and is developing a sense of self – which develops around 8-9 years of age and isn’t developed or is severely underdeveloped in psychopaths (and other personality disorders as well). Her earlier experiences would make anyone who wants to work in the field of clinical psychology cringe. But when you start seeing what can result from taking a case like this, it seems like it’s worth it. I don’t know how it would reflect on an evaluation with the PCL-R at the moment, but if she continuous to evolve in the same direction, with the same therapist, in a few years is likely that she no longer qualifies for an assessment of psychopathy, although she will always score higher than the majority. Also those core affective traits will probably continue to exist, however, it seems like work has been done to make them be less of an issue.

    • Well-Wisher says

      I guess she is quite different from the usual psychopath for wanting to go into therapy. The other I have seen is the blogger on sociopathworld, who tackles his condition with mindfulness practice, though definitely seems comfortable with his state.

      Those in correctional settings very rarely elect to go into therapy with noble intentions, a major part of the reason that traditional therapies do not work. It certainly hasn’t been studied whether psychopaths who genuinely want to be treated benefit from therapy, for the above reason. Traditional therapies generally tend to only provide coping strategies through cognitive control and try to change maladaptive beliefs, which can treat transient disorders such as depression into clinical insignificance, but provide what is often at most moderate benefit for the management of even willing personality disorder patients, who have strong indications of neurocognitive and affective dysfunction at the core of their conditions.

      The Hare’s PCL-R isn’t an accurate measure of how psychopathic characteristics change over time, and it is strongly argued whether it is even an accurate definition and measure of psychopathy (it places what is argued to be undue focus on the antisocial behavior characteristics, reflecting the traditional “criminal psychopath”). Personally, I think the triarchic model presents a better conception of psychopathy.

      • MA32 says

        The PCL-R is what we have, although some scientists are trying to build a better one that isn’t a 2 factor model, having the PCL-R as a basis. There are ways of knowing the best kind of person to be an evaluator and if the evaluation is made by the same person, some of the intra-personal factors that influence the diffrence in scoring are mitigated. But no, it’s not perfect. However we can’t simply dismiss studies that show remarkable changes that accompany the PCL-R score. I take the case study I’ve read with a grain of salt though (and yes, there are a few studies emerging on that subject)

      • MA32 says

        These reminds me of a time in which I stoped and asked myself wether someone who was previously assessed psychopathic and diagnosed ASPD and no longer meets the DSM criteria or scores above 30 is still a psychopath. I think as with any other disorder if the person doesn’t meet the criteria, she is no longer a psychopath. But that doesn’t mean everything is perfectly fine.

        • Well-Wisher says

          The high cut-off for a formal diagnosis of psychopathy of 30 out of 40 makes it possible to have many significant psychopathic traits while still failing to qualify for the diagnosis. In the UK the cut-off is 25, but this may make it vulnerable to false positives that reflect ASPD. If a person were to score a perfect score on Factor 1 of the PCL-R (interpersonal-affective core) but only score up to 12 points out of 24 on Factor 2 (antisocial-lifestyle-miscelaneous) (a still significant score, considering that a typical person has a total PCL-R score of 5-6), thus reflecting what is theorized to be “successful psychopathy” (I dislike the term, but this term is even used in science), that person would not reach the cut-off, and is thus, not a psychopath. I do not like to think that not qualifying for a disorder diagnosis means that you do not have any problems.

          • MA32 says

            That’s what I was saying from the beginning. But think of someone who had a score of say 34 and is now 27 (just an abstract example, but I could also give a real one of someone who scored 29 and ended up with 19) – that’s a huge difference for a personality construct/disorder.

  3. Anon says

    ‘…if she continuous to evolve in the same direction, with the same therapist, in a few years is likely that she no longer qualifies for an assessment of psychopathy, although she will always score higher than the majority. Also those core affective traits will probably continue to exist, however, it seems like work has been done to make them be less of an issue….’

    There is no cure for psychopathy. No way of magically causing neuroreceptors to appear and begin functioning…no way of developing the amygdala to full function.

    The core affective traits define psychopathy. If they’re always there, so is the psychopathy.

    At best, the diagnosis can be mitigated by aligning self-interest with pro-social behavior, but the demons will always be lurking in the shadows. At the right moment, given the right stimulus, they will reappear. Always and forever.

    • MA32 says

      I see things differently. For me, a psychopath is someone who is callous, unempathetic and also severely antisocial and scores higher than 30 (and for some countries 25) in the PCL-R. The affective traits will be there always for sure. But the affective traits (only) don’t make the psychopath. It’s rather a combination of traits and behavioural manifestations – and a long list of them. How many do you think are there with those core affective traits that never had major issues regarding their functioning in society? These people aren’t psychopaths. And if someone has them but is no longer functionally impaired and scores below 30, that people isn’t a psychopath either. Tumblr, for instance is full of people that have those traits (or other subset of psychopathic/ASPD traits) and think they’re psychopaths/ASPD because of it, but they’re wrong and no therapist ever would diagnose or assess them, because that’s not how it works. However, someone who was once assessed psychopathic will still score pretty high, even if they score below 30 (as I said). Also, Jess is that you?

    • Well-Wisher says

      It has been argued that as a genetically significant (recent studies suggest a “very strong” genetic influence on callous and unemotional, i.e. precursor psychopathic, traits in children) developmental disorder with strong indications of neurobiological dysfunction, a treatment for psychopathy should aim to directly influence the dysfunctional neural substrates to function properly. To that end, invasive and noninvasive electrical and magnetic stimulation, which has shown promise in treating a wide range of disorders, has been proposed to normalize the brain function of psychopathic patients, and every year new findings in the active field of the neurobiological study of psychopathy may allow us to find pharmacological targets to treat psychopathy’s cognitive and emotional deficiencies.

      Psychopaths are not the only ones with brains that do not work properly. Neurobiological dysfunction has been observed in all mental disorders, opening the way to develop neurobiology-based treatments that may allow us to treat these disorders with unprecedented effectiveness. It annoys me that psychopathy is treated with such pessimism. Even autism research is optimistic. Popular articles about psychopathic criminals with comment sections abound with commenters suggesting that we “should lock them away and throw away the key”, or that they should be executed by vigilantes with no trial or appeal. Such vitriol makes me doubt the compassionate capacity of the empathically functional members of society.

      Neuropsychiatry is a field that is still in its infancy, and so is the neurobiological study of psychopathy. Do not be so pessimistic for its treatment prospects.

      • MA32 says

        Well, I don’t think that the comment was directed to me (because I wasn’t the pessimistic here), but I must tell that what you said is true, but try to imagine what is to convince a psychopath, who is ambiguous about treatment in the first 2 years or so, to go for a treatment that causes changes like those to occur in their brain.

  4. Anon says

    Popular articles about psychopathic criminals with comment sections abound with commenters suggesting that we “should lock them away and throw away the key”, or that they should be executed by vigilantes with no trial or appeal. Such vitriol makes me doubt the compassionate capacity of the empathically functional members of society.

    I doubt that you can adduce any kind of meaningful world view from the comments section of the tabloid press. Of course, those responsible for particularly heinous crimes rouse the sensibilities of the crowd. ’twas always thus. Personally, I wouldn’t conflate ‘psychopath’ and ‘heinous criminal’ although there’s often some degree of overlap….that said, ‘an eye for an eye, a tooth for a tooth’ doesn’t seem an unreasonable approach to someone who tortures, kills, and/or rapes. Perhaps it’s easier to look at it as having empathy for the victim, rather than the perpetrator.

    Neuropsychiatry is a field that is still in its infancy, and so is the neurobiological study of psychopathy. Do not be so pessimistic for its treatment prospects.

    As things currently stand, there is no cure for psychopathy and, even if there was, why would a psychopath even want to be cured? Would an empath willingly forgo the world of emotion and feeling?

    • Well-Wisher says

      “Currently” ; )

      As things currently stand, there is no cure for psychopathy and, even if there was, why would a psychopath even want to be cured? Would an empath willingly forgo the world of emotion and feeling?

      That is a significant issue at the heart of many discussions about treatment. Personality disordered patients tend to not see anything wrong with their abnormal personalities, even if it causes them serious problems (in psychiatry, this is called “lack of insight”, or “ego-syntonicity” as I mentioned above. Insight is not only knowing that you have a disorder, but also knowing that it needs treatment). This alone makes treating them very difficult, as they wouldn’t seek treatment in the first place. If mental disorders without serious disconnects to reality (e.g. psychosis) were classified exclusively according to how willing the people with them are to get treatment, then along with anorexia nervosa, almost the entire personality disorder group would likely not qualify.

      Any treatment for psychopathy that would be developed would most likely target those who already can be identified as such in systems where they can be committed due to justice or harm potential: prisons or psychiatric hospitals. While psychopathic inmates do not make an effort to get treatment, they still do participate voluntarily in treatment programs, as the multitude of studies on treatment attempts can attest. While a inmate psychopath isn’t in a hurry to be cured, the way I see it, they would be willing to take part in a treatment program that actually works in exchange for a chocolate allowance (it helps that life’s little pleasures are magnified in a prison environment). Of course, getting “community psychopaths”, the population where Jessica is from, who are not under pressure to be treated, to agree to treatment is a different matter.

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