Type in “psychopath” or “sociopath” in your Internet search engine, and you will likely get millions of results. The condition continues to intrigue and puzzle laymen and physicians alike. As Maughs noted over 70 years ago, even by that time the condition had been recognized by medicine for a century and a half, variably referred to among professionals as:
…melancholia sans delire, manie sans delire, impulsive homicidal mania, moral insanity, reasoning insanity, insanity of the acts, moral imbecility, moral idiocy, constitutional defective, defective delinquent, emotionally unstable or inferior, neurotic constitution, instinct character, constitutional immorality, sociopathy, psycho-satipath, etc.1
The boundaries and even core characteristics of these entities differ substantially, and all map poorly onto modern constructs. Nonetheless, our current concepts cannot be fully understood without some understanding of their intellectual lineage.
Moral Insanity and the Hereditary Taint
J. C. Prichard is generally credited with introducing the concept of “moral insanity” in 1835:
There is a form of mental derangement in which the intellectual functions appear to have sustained little or no injury, while the disorder is manifested principally or alone in the state of the feelings, temper or habits. In cases of this nature the moral or active principles of the mind are strangely perverted or depraved; the power of self-government is lost or greatly impaired and the individual is found to be incapable, not of talking or reasoning upon any subject proposed to him, but of conducting himself with decency and propriety in the business of life.2
Although his conceptualization owed much to Pinel’s idea of manie sans delire, prior to that time, the question of why some individuals were habitual wrongdoers seems to have been mainly one for philosophers or theologians rather than for physicians to address.
But although the term is beguiling, in fact, Prichard’s conceptualization was far different (and aimed at different ends) than more modern ideas about antisocial behavior;3 and perhaps Benjamin Rush’s idea that partial or complete “perversion of the moral faculties” with sparing of the intellect could result from “corporeal disease” or even congenital factors is closer to today’s conceptualization of either sociopathy or psychopathy.4 But the initial debate was one of nosology—how to classify cases involving pathological deviation from what might be considered natural expression of feelings, impulses, or inclinations that did not involve derangement of intellect, reasoning, or perception (ie, intellectual deficit or psychosis). Although such cases could involve criminal or otherwise wrongful behavior as either an incidental or central characteristic, obviously the conceptual space included various behaviors—not to mention giving physicians the opportunity to label any number of nonstandard beliefs or practices as pathological.
Toward the latter part of the 19th century, the debate focused somewhat more on the issue of repetitive criminality—a characteristic theorized to be the manifestation of a heritable tendency to “degeneration”—increasing in severity and ultimately causing the affected families or groups to die off in three or four generations. It was associated with a variety of other conditions such as feeble-mindedness or epilepsy5 as well as an intellectual tradition, most closely associated with Lombroso,6 in which certain specified biologic and developmental features were said to indicate the “born criminal.” These were held to be indicative of atavism or regression to a more primitive (ape-like) physical form and, in the best European tradition of the time, also said to be frequently found among “savages.” Gouster7 noted that such individuals tended to show characteristics of (1) malice, disobedience, and dishonesty from infancy; (2) tended to show poor judgment and to be overly excitable and hypochondriacal as adults; (3) frequently had physical anomalies (asymmetrical facies and crania, malformations of the external ear); and (4) often had a hereditary taint—ancestors who were criminal, intellectually impaired, epileptic, or otherwise seen as deficient. This line of thought led, particularly in England, to the concept of the “moral imbecile”—persons who “from an early age display some permanent mental defect coupled with strong vicious or criminal propensities on which punishment has had little or no deterrent effect.”8
Constitutional Psychopathic Inferiority
Around the same time, Koch introduced the concept of “psychopathic inferiority,” intending this term to encompass:
…all abnormalities—either hereditary or acquired—which influence a human’s personal life, but which do not constitute—even in their worst cases—mental illnesses, although the persons suffering from them do not seem to be of a sound mind and sound physical capabilities.9
Koch further subdivided this state into psychopathic predisposition, defect, or degeneration, based on increasing severity of symptoms. Much as later theorists first conceptualized “borderline” states, psychopathic inferiority was seen as a heterogeneous condition occupying a middle ground of severity between “neurosis” and “psychosis.” Kraepelin struggled with how to classify this group, suggesting a number of subtypes but changing his views substantially between different editions of his influential textbook.10 Somewhat later, Schneider broadly characterized such afflicted individuals as “abnormal personalities who suffer from their abnormality or cause society to suffer”—making the point that “abnormal” in this sense was intended to imply only statistical deviation, differing in severity but not kind from individuals with “neurotic” illnesses, and thus representing points on a continuum of illness rather than constituting a distinct pathological entity.11 Both included within that group a wide range of pathologies, many of which would today be classified among the personality disorders.
The concept appears to have travelled slowly to the US, but gained currency by the early 20th century. Many individuals considered to be “constitutional psychopathic inferiors” were seen as unintelligent and often prone to “neurasthenia”; generally not troublesome, but slow workers liable to become symptomatic when displaced from their accustomed and undemanding mode of life. A second group, however, was described as being made up of:
…a large number of drug habitues and criminals, especially minor criminals and an excessive proportion of persons who clutter up court dockets in one way or another. They exhibit selfish indifference to the rights of others which gets them into difficulties from which they extricate themselves without much regard for consequences to associates…The problem of handling them is as much a problem of the law as it is of medicine.12
Early on, “hereditary taint,” a variety of abnormalities in emotional response, and a sharp contrast between apparently normal intelligence and a pattern of poor judgment were emphasized as characteristic of the condition. One typology described some personality styles that would be easily recognized today (eg, the paranoid personality group, the emotionally unstable group), but also included a variety of other subtypes or groups: “inferior or inadequate,” sexual deviates, pathological liars, criminals, and those suffering from “nomadism” (or hobos).13
Over the ensuing two decades, as more emphasis was placed on the connection to dissocial behavior, terms such as “psychopathy” or “psychopathic personality” increasingly came into vogue. By the 1940s, superego defects (whether caused by nature or nurture) were seen as causing the defining features of the “psychopath”: antisocial conduct, ruthlessness, selfishness, impulsivity, and violence.14
Cleckley, in his classic treatise The Mask of Sanity, vividly described this condition:
…The observer [of the psychopath] is confronted with a convincing mask of sanity. All the outward features of this mask are intact; it cannot be displaced or penetrated by questions directed toward deeper personality levels… Logical thought processes may be seen in perfect operation no matter how they are stimulated or treated under experimental conditions. Furthermore, the observer finds verbal and facial expressions, tones of voice, and all the other signs we have come to regard as implying conviction and emotion and the normal experiencing of life as we know it ourselves and as we assume it to be in others. All judgments of value and emotional appraisals are sane and appropriate when the psychopath is tested in verbal examinations.
Only very slowly and by a complex estimation or judgment based on multitudinous small impressions does the conviction come upon us that, despite these intact rational processes, these normal emotional affirmations, and their consistent application in all directions, we are dealing here not with a complete man at all but with something that suggests a subtly constructed reflex machine that can mimic the human personality perfectly…So perfect is this reproduction of a whole and normal man that no one who examines the psychopath in a clinical setting can point out in scientific or objective terms why, or how, he is not real. And yet we eventually come to know or feel we know that reality, in the sense of full, healthy experiencing of life, is not here.15
For Cleckley, perhaps the most striking characteristic of such individuals was an appalling lack of empathy (or indeed ability to experience any strong, enduring emotion), and he initially argued that the degree of dysfunction was so severe that the condition should be considered a psychosis. Although he later reconsidered this view, he maintained that by any reasonable definition it constituted a genuine disorder, as legitimate as any other psychiatric condition, and proposed 16 characteristics that defined it (Table 1). These characteristics were later expanded somewhat by Hare16 into the initial Psychopathy Checklist, an instrument that has, with subsequent modifications, been widely adopted by researchers and clinicians.17
Cleckley’s List of Psychopathic Characteristics
Sociopathy and Antisocial Personality Disorder
By this time, roughly the 1930s to 1940s, a more or less parallel line of thinking had evolved, largely derived from the field of criminology. If indeed the psychopath was distinguished by an absence of intrapsychic conflict, would it not be more accurate to describe “a group of persons distinguished by anomaly in the social sphere primarily” instead as “sociopathic”18? Moreover, although it had been long accepted that the psychopath often demonstrated a number of behavioral problems (eneuresis, fire-setting, truancy, and the like) early on, were such “warning signs” truly more common than in children who grew up to be normal? Was there a “natural history” or predictable course of development leading to the end-point of psychopathy? To best answer such questions, a cohort study design was needed.
Sometime in the mid-1950s, Lee Robins, PhD, then a young sociologist working as a research assistant in the Department of Psychiatry at Washington University in St. Louis, obtained medical records from a child guidance clinic that had been established by the city in 1922.19 A total of 524 subjects were identified (along with 100 controls identified from public school records). After eliminating 23 known to have died before age 25, Robins and colleagues attempted to trace and interview the remaining 601 subjects, some 30 years later. Remarkably, 481 could be found and assessed. The result was another classic work, Deviant Children Grown Up.19
What Robins found was that, indeed, problem behaviors in childhood predicted “sociopathic personality” in adulthood:
The maladjustment of the patients showed itself in the high rate of arrests, low occupational achievement, their mental hospitalizations and numerous subjective symptoms, high divorce rates, alienation from friends, relatives, church, and all kinds of organizations, extensive use of welfare services, frequent moves, excessive use of alcohol, and the transmission of behavior problems to their children.19
Looking systematically at criminals, Guze20 found the same pattern; nearly 80% of a sample of 299 felons qualified for diagnosis of sociopathy or antisocial personality disorder, using the same symptoms Robins had identified, including problems beginning in childhood or adolescence.
The use of the same set of explicit criteria for diagnosis was hardly the result of chance: Robins was married to Eli Robins, like Guze a psychiatrist at Washington University, and they, with their colleagues in that department (particularly George Winokur), had long been working to validate and improve the reliability of a number of psychiatric diagnoses, including sociopathy or Antisocial Personality Disorder,21 an effort that was to profoundly reshape psychiatric diagnosis.22
Prior to that time, diagnostic standards were more descriptive than explicit. In the American Psychiatric Association’s first Diagnostic and Statistical Manual (DSM),23 the diagnosis of “Antisocial Reaction” was applied to:
…chronically antisocial individuals who are always in trouble, profiting neither from experience nor punishment, and maintaining no real loyalties to any person, group, or code. They are frequently callous and hedonistic, showing marked emotional immaturity, with lack of sense of responsibility, lack of judgment, and an ability to rationalize their behavior so it appears warranted, reasonable, and justified….
With DSM-II,24 this condition was renamed Antisocial Personality, but was otherwise little changed:
This term is reserved for individuals who are basically unsocialized and whose behavior pattern brings them repeatedly into conflict with society. They are incapable of significant loyalty to individuals, groups, or social values. They are grossly selfish, callous, irresponsible, impulsive, and unable to feel guilt or learn from experience and punishment…
But the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III),25 for the first time explicitly set out guidelines for the diagnosis of Antisocial Personality Disorder (ASPD) (Table 2), which were largely adapted from the earlier Washington University criteria. Critics of that formulation pointed out that although reliance on specific behaviors might improve diagnostic reliability, it risked simultaneously being overly broad (thus constituting a psychologically and biologically heterogeneous group) and too narrow, by excluding individuals with psychopathic personality characteristics but who did not demonstrate (or at least report) the specific behaviors required for diagnosis.26 Perhaps as a response to that concern, subsequent criteria sets have focused more on behavorial styles (eg, recklessness, lack of remorse, impulsivity) rather than on specifying the behaviors themselves (Table 3).
DSM-III Criteria for Antisocial Personality Disorder
DSM-IV and DSM-5 Criteria for Antisocial Personality Disorder
The Current Status of Psychopathy and Antisocial Personality Disorder
Those were not the only concerns about the validity of the diagnosis. Cleckley15 explicitly remarked on the absence of anxiety or, indeed, strong emotion in the individual diagnosed as having psychopathy; focused more on observable behaviors, the Washington University criteria did not address emotionality directly. But it soon became apparent that however defined, the groups were heterogeneous in terms of comorbid anxiety and depression as well as in related psychobiologic measures, which has led to suggestions of dividing them into primary and secondary forms.27–29
Moreover, differentiation between addiction and ASPD can particularly be challenging because some behaviors (financial default, violence, recklessness, and the like) in practice frequently overlap between the constructs and because the association might go both ways—that is, “primary” sociopaths might be at elevated risk for substance use because of the impulsivity and poor judgment that is typical of the condition, whereas “primary” substance users might secondarily become involved in a variety of dissocial behaviors because of addiction. However, requiring presence of antisocial symptoms independently of substance use to diagnose ASPD substantially worsens diagnostic reliability without improving validity.30–32
Prior to the publication of DSM-5,33 such issues could be addressed by making multiple diagnoses and using a multiaxial format (eg, noting comorbid substance abuse or dependence, anxiety syndromes, or depressive disorders on Axis I and ASPD on Axis II), although this risked downplaying the salience of the diagnosis unless it was specified as being principal.34 With DSM-5, the principal diagnosis is generally the one listed first—although this convention remains somewhat arbitrary, particularly because, in treatment settings, the individual is likely to present for complaints related to comorbid conditions, thus by convention making (for example) a substance use disorder “primary” and potentially again obscuring the role of ASPD.
Despite these concerns, the agreement between psychopathy (as assessed by different versions of the Psychopathy Checklist) and ASPD (as defined by different editions of DSM) has been consistently fairly high.15,35 The prevalence of ASPD, both in the general population and in correctional settings, is substantially greater than psychopathy (probably 3 or 4:1), with psychopathy being nested within the larger group and distinguished by greater severity and pervasiveness of antisocial behaviors.36,37
The intellectual development of the concept of psychopathy or sociopathy has been anything but linear. Over time the condition has been seen as primarily due to defect of innate moral qualities; conceptualized as being only one aspect of a profoundly variable form of psychopathology that could be inborn or acquired; equated with atavism, degeneration, and hereditary taint; considered the example par excellence of superego failure; and characterized by either profound emotional deficit or by consistent inability to function properly in society. For decades, even what to call the condition was a matter of dispute.
There remains dispute as to where to draw the boundaries of the condition; as with other psychiatric illnesses, although liability is not normally distributed in the general population, there is no clear “point of rarity” by which the affected and unaffected can be unequivocally separated. Too restrictive a definition risks missing typical or average cases, whereas an overly inclusive definition risks too much heterogeneity, thereby undermining studies of etiology and treatment. The validity of the concept, however, is bolstered by the fact that two means of assessment converge on the same core group, differing in severity rather than essential characteristics.
- Maughs S. A concept of psychopathy and psychopathic personality: its evolution and historical development. Part one. J Crim Psychopathol. 1941;2:329–356.
- Prichard JC. A Treatise on Insanity and Other Disorders Affecting the Mind. London: Sherwood, Gilbert & Piper; 1835. doi:10.1037/10551-000 [CrossRef]
- Berrios GE. J.C. Prichard and the concept of “moral insanity.” Classic text no. 37. Hist Psychiatry. 1999;10(37):111–126. doi:10.1177/0957154X9901003706 [CrossRef]
- Rush B. Medical Inquiries and Observations Upon Diseases of the Mind. Philadelphia, PA: Kimber and Richardson; 1812.
- Morel B-A.Traite des Degenerescences Physiques, Intellectuelles et Morales de l’Espece Humaine. J-B Bailliere, Paris; 1839.
- Lombroso C. Crime: Its Causes and Remedies (trans. ). Boston, MA: Little Brown; 1911.
- Gouster M. Moral insanity. Rev Scientific Med. 1878;38:115–131.
- Maughs S. A concept of psychopathy and psychopathic personality: its evolution and historical development. Part two. J Crim Psychopathol. 1941;2:465–499.
- Gutman P. Julius Ludwig August Koch (1841–1908): Christian, philosopher and psychiatrist. Hist Psychiatry. 2008;19(74 Pt2):202–214. doi:10.1177/0957154X07080661 [CrossRef]
- Lewis A: Psychopathic personality: a most elusive category. Psychol Med. 1974;4:133–140 doi:10.1017/S0033291700041969 [CrossRef]
- Mayer-Gross W, Slater E, Roth M: Clinical Psychiatry. Baltimore, MD: Williams and Wilkins; 1956:91–186.
- House W. Constitutional psychopathic inferiority. Cal State J Med. 1923;21(1):26–29.
- Orbison TJ. Constitutional psychopathic inferior personality-with or without psychosis. Cal West Med. 1929;30(2):78–83.
- Maughs S. Psychopathic personality. Review of the literature, 1940–47. Clin Psychopathol. 1949;10(3):247–275.
- Cleckley H. The Mask of Sanity. St. Louis, MO: C.V. Mosby; 1982.
- Hare RD. Diagnosis of antisocial personality disorder in two prison populations. Am J Psychiatr. 1983;140(7):887–890. doi:10.1176/ajp.140.7.887 [CrossRef]
- Brook M. The role of psychopathic and antisocial personality traits in violence risk assessment: implications for forensic practice. Psychiatr Ann. 2015;45(4):175–180.
- Partridge GE. Current conceptions of psychopathic personality. Am J Psychiatr. 1930;87(1):53–99. doi:10.1176/ajp.87.1.53 [CrossRef]
- Robins L. Deviant Children Grown Up. Baltimore, MD: Williams and Wilkins; 1966.
- Guze SB. Criminality and Psychiatric Disorders. New York, NY: Oxford University Press; 1976.
- Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatr. 1972;26(1):57–63. doi:10.1001/archpsyc.1972.01750190059011 [CrossRef]
- Decker HS. The Making of DSM-III. New York, NY: Oxford University Press; 2013.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Association; 1952.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Association; 1968.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC, American Psychiatric Association; 1980.
- Hare RD, Hart SD, Harpur TJ. Psychopathy and the DSM-IV criteria for antisocial personality disorder. J Abnorm Psychol. 1991;100(3):391–398. doi:10.1037/0021-843X.100.3.391 [CrossRef]
- Lykken DT. A study of anxiety in the sociopathic personality. J Abnorm Psychol. 1957;55(1):6–10. doi:10.1037/h0047232 [CrossRef]
- Lorber MF. Psychophysiology of aggression, psychopathy, and conduct problems: a meta-analysis. Psychol Bull. 2004;130(4):531–552. doi:10.1037/0033-2909.130.4.531 [CrossRef]
- Skeem JL, Poythress N, Edens JF, Lilienfeld SO, Cale EM. Psychopathic personality or personalities? Exploring potential variants of psychopathy and their implications for risk assessment. Aggress Violent Beh. 2003;8(5):513–546. doi:10.1016/S1359-1789(02)00098-8 [CrossRef]
- Carroll KM, Ball SA, Rounsaville BJ. A comparison of alternative systems for diagnosing antisocla personality disorder in cocaine abusers. J Nerv Ment Dis. 1993;181(7):436–443. doi:10.1097/00005053-199307000-00006 [CrossRef]
- Dinwiddie SH, Reich T. Attribution of antisocial symptoms in coexistent antisocial personality disorder and substance abuse. Compr Psychiatry. 1993;34:235–243. doi:10.1016/0010-440X(93)90004-N [CrossRef]
- Dinwiddie SH, Daw EW. Temporal stability of antisocial personality disorder: blind follow-up study at 8 years. Compr Psychiatry. 1998;39(1):28–34. doi:10.1016/S0010-440X(98)90029-3 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2014.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
- Widiger TA, Cadoret R, Hare R, et al. DSM-IV antisocial personality disorder field trial. J Abnorm Psychol. 1996;105(1):3–16. doi:10.1037/0021-843X.105.1.3 [CrossRef]
- Coid J, Yang M, Ullrich S, Roberts A, Hare RD: Prevalence and correlates of psychopathic traits in the household population of Great Britain. Int J Law Psychiatry. 2009;32(2):65–73. doi:10.1016/j.ijlp.2009.01.002 [CrossRef]
- Coid J, Ullrich S. Antisocial personality disorder is on a continuum with psychopathy. Compr Psychiatry. 2010;51:426–433. doi:10.1016/j.comppsych.2009.09.006 [CrossRef]
Cleckley’s List of Psychopathic Characteristics
Superficial charm and good “intelligence”
Absence of delusions and other signs of irrational thinking
Absence of “nervousness” or psychoneurotic manifestations
Untruthfulness and insincerity
Lack of remorse and shame
Inadequately motivated antisocial behavior
Poor judgment and failure to learn by experience
Pathological egocentricity and incapacity for love
General poverty in major affective reactions
Specific loss of insight
Unresponsiveness in general interpersonal relations
Fantastic and uninviting behavior with drink and sometimes without
Suicide rarely carried out
Impersonal, trivial, and poorly integrated sex life
Failure to follow any life plan
DSM-III Criteria for Antisocial Personality Disorder
|Current age at least 18 years
Onset before age 15 years as indicated by a history of three (or more) of the following:
At least four of the following manifestations of the disorder since age 18 yearsa:
Truancy (positive if it amounted to at least 5 days per year for at least 2 years, not including the last year of school)
Expulsion or suspension from school for misbehavior
Delinquency (arrested or referred to juvenile court because of behavior)
Running away from home overnight at least twice while living in parental or parental surrogate home
Repeated sexual intercourse in a casual relationship
Repeated drunkenness or substance abuse
School grades markedly below expectations in relation to estimated or known IQ (may have resulted in repeating a year)
Chronic violation of rules at home and/or at school (other than truancy)
Initiation of fights
A pattern of continuous antisocial behavior in which the rights of others are violated, with no intervening period of at least 5 years without antisocial behavior between age 15 years and the present time
Antisocial behavior is not due to either severe mental retardation, schizophrenia, or manic episodes
Inability to sustain consistent work behavior
Lack of ability to function as a responsible parent
Failure to accept social norms with respect to lawful behavior
Inability to maintain enduring attachment to a sexual partner
Irritability or aggressiveness as indicated by repeated physical fights or assault
Failure to honor financial obligations
Failure to plan ahead or impulsivity
Disregard for the truth, as indicated by repeated lying, use of aliases, and “conning” others for personal profit
DSM-IV and DSM-5 Criteria for Antisocial Personality Disorder
|There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
The individual is at least age 18 years
There is evidence of conduct disorder with onset before age 15 years
The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
Impulsivity or failure to plan ahead
Irritability and aggressiveness, as indicated by repeated physical fights or assaults
Reckless disregard for safety of self or others
Consistent irresponsibility, as indicated by repeated failure to sustain current work behavior or honor financial obligations
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another