History of psychopathy  

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 This page History of psychopathy is part of psychopathology series. Illustration: the head of Elagabalus, one of the five "mad emperors" of ancient Rome
This page History of psychopathy is part of psychopathology series.
Illustration: the head of Elagabalus, one of the five "mad emperors" of ancient Rome

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Train wreck at Montparnasse (October 22, 1895) by Studio Lévy and Sons.
Train wreck at Montparnasse (October 22, 1895) by Studio Lévy and Sons.

Psychopathy has a long history from an initially very general concept that gradually narrowed to the current one.

Early history

In very general terms, behaviors related to a modern concept of "antisocial personality" have been informally noted in a brief vignette by Theophrastus in Ancient Greece, whose The Unscrupulous Man "will go and borrow more money from a creditor he has never paid ... When marketing he reminds the butcher of some service he has rendered him and, standing near the scales, throws in some meat, if he can, and a soup-bone. If he succeeds, so much the better; if not, he will snatch a piece of tripe and go off laughing". Figures of insanity (e.g. vagabonds, libertines, the "mad") have often, at least since the 18th century, represented an image of darkness and threat to society, as would later "the psychopath", a mixture of concepts of dangerousness, evil and illness.

Clinical concepts that might in some aspects be related to theories of psychopathy today are thought to have emerged in the early 19th century. In 1801, Philippe Pinel described, without moral judgment, patients who appeared mentally unimpaired but who nonetheless engaged in impulsive and self-defeating acts. He described this as Manie sans délire (insanity without confusion or delusion) or la folie raisonnante (rational insanity), and his anecdotes generally described people carried away by instincte fureur (instinctive fury). Benjamin Rush wrote in 1812 about individuals with an apparent "perversion of the moral faculties" which he saw as a sign of innate defective organization. He also saw such people as objects of compassion whose mental alienation could be helped, even if that needed to be in prisons or what he referred to as the "christian system of criminal jurisprudence". In 1835 James Cowles Prichard developed a broad diagnostic category called moral insanity, referring to "madness" of emotional or moral dispositions without significant delusions or hallucinations. Prichard generally referred more to eccentric behaviour than out of control passions, though his diagnosis became widely used. None of these concepts are directly comparable to later diagnostic categories of psychopathy in the specific sense, or even to personality disorders. Moreover, "moral" did not necessarily refer at that time to morality, it could just mean psychological or emotional.

The (pseudo) scientific study of individuals thought to lack a conscience flourished in the latter half of the 19th century. Notably, Cesare Lombroso rejected the view that criminality could occur in anyone and sought to identify particular "born criminals" whom he thought showed certain physical signs, such as proportionately long arms or a low and narrow forehead. Towards the turn of the 20th century, Henry Maudsley had begun writing about the "moral imbecile", "moral insanity" and "criminal psychosis". He saw these as genetic disorders for which individuals could be neither punished nor reformed by the correctional system, and applied the concepts to what he saw as a lower class of chronic offenders who he described in various negative ways by comparison to "the higher industrial classes".

In 1891 Julius Ludwig August Koch formally introduced the concept of "psychopathic inferiority" (psychopathischen minderwertigkeiten). This also referred to diverse kinds of dysfunction or strange conduct in the absence of obvious mental illness or retardation. Koch was a Christian and influenced by the degeneration theory popular at the time, though he referred to both congenital and acquired types. Habitual criminality was only a small part of his concept, but the public soon used the shortened version "inferiors" to refer to anyone supposedly suffering from an inherent disposition toward crime.

20th century

Emil Kraepelin included a section on moral insanity in his psychiatric classification scheme but by 1904 was referring to psychopathic conditions. Also influenced by degeneration theory, Kraepelin eventually included several categories involving antisocial or criminal behavior, as well as a dissocial type, including: born criminals (inborn delinquents), liars and swindlers, querulous persons, and driven persons (including vagabonds, spendthrifts, and dipsomaniacs). After World War I psychiatrists dropped the term "inferiors" (minderwertigkeiten) and used psychopathisch instead, and its derivatives psychopathie and psychopathen. This was an attempt to avoid assumptions of inferiority and degeneracy, and to be neutral and scientific, and referred not just to antisocial behaviors but a wide range of issues. Kurt Schneider and Karl Birnbaum were also influential in attempting a more scientific classification of psychopathy, defined broadly in terms of abnormal personalities. Schneider proposed a "compassionless" type and a "willenlos" (weak-willed) type; Birnbaum an "amoral" type and a "haltlos" (lacking resilience or stability) type. Birnbaum also used the term "sociopathic", which would become influential from the late 1920s in America.

Nevertheless, in the first decades of the 20th century, "constitutional psychopathic inferiority" became a commonly used term in the US, implying the issue was inherent to the genetics or makeup of the person, an organic disease. As a category it was used to target any and all dysfunctional or antisocial behavior, and in psychiatric categorization it labeled a broad range of alleged mental deviances, including homosexuality. Some courts began to develop "psychopathic laboratories" for the classification and treatment of offenders; the term psychopathic was chosen to avoid the social stigma of "lunacy" or "insanity", while emphasizing variance from normality rather than simply a mental hygiene issue. Nevertheless, at least one such laboratory issued a report on eugenic sterilization initiatives. From the 1930s, "sexual psychopath" laws (a term going back to Richard von Krafft-Ebing) started to be implemented in many US states, allowing for the indeterminate psychiatric commitment of sex offenders.

George Partridge, while narrowing the definition of psychopathy to antisocial personality, emphasized that at least some types appeared to be about social maladjustment due to social learning, and argued that the term sociopath should be used. David Henderson published in 1939 a theory of "psychopathic states" which, although he described different types and unusually suggested that psychopaths might not all be criminals, included a violently antisocial type which ended up contributing to that being the popular meaning of the term. In the 1940s a diagnosis of autistic psychopathy was introduced, later coming to wider notice and renamed Asperger syndrome to avoid the stigma of the term psychopathy.

The Mask of Sanity by Hervey M. Cleckley, M.D., first published in 1941, is considered a seminal work which provided a vivid series of case studies of individuals described as psychopaths. Cleckley proposed 16 characteristics of psychopathy, derived mainly from his work with male psychiatric patients in a locked institution. The title refers to the "mask" of normal functioning that Cleckley thought concealed the disorganization, amorality and disorder of the psychopathic personality. This marked the start in America of the current clinical and popularist conception of psychopathy as a particular type of antisocial, emotionless and criminal character. Cleckley would produce five editions of the book over subsequent decades, including a substantial revision in 1950, expanding his case studies and theories to more non-prisoners and non-criminals.

The first version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in 1952 did not use the term psychopath, but instead "sociopathic personality disturbance", although it included many of Cleckley's criteria. The diagnosis had antisocial or dyssocial subtypes, though the latter was deleted in the DSM-II. The diagnosis was only one within a broader category that would be termed personality disorders.

Cleckley's concept of psychopathy, particularly in the sense of a conscience-less man beneath a mask of normality, caught the public imagination. However, the book fell out of favor, and when he died in 1984 Cleckley was better remembered for a vivid case study of a female patient published in 1956, turned into a movie The Three Faces of Eve in 1957, which had (re)popularized in America another controversial diagnosis, Multiple Personality Disorder.

A distinction was proposed by psychoanalyst Benjamin Karpman from the 1940s between psychopathy due to psychological problems (e.g. psychotic, hysterical or neurotic conditions) and idiopathic psychopathy where there was no obvious psychological cause. He concluded that the former could not be attributed to a psychopathic personality and that the latter appeared so absent of any redeeming features that it couldn't be seen as a personality issue either, but must be a constitutional "anethopathy" (amorality or antipathy). Various theories of distinctions between primary and secondary psychopathy remain to this day. Meanwhile, criminologist sociologists William and Joan McCord were influential in narrowing the definition of psychopathy to an antisocial lack of the guilt emotion and reactive aggression. On the other hand, various analysts purported to identify "successful" psychopaths in society, some even suggesting it was but an adaption to the social or economic mores of the age, others noting they could be hard to spot either because they were so good at hiding their lack of conscience, or because many people showed the traits to some degree.

However, there remained no international clinical agreement on the diagnosis of psychopathy. A 1977 study found little relationship with the characteristics commonly attributed to psychopaths and concluded that the concept was being used too widely and loosely. Robert D. Hare had published a book in 1970 summarizing research on psychopathy, and was subsequently at the forefront of psychopathy research. Frustrated by a lack of agreed definitions or rating systems for psychopathy, including at a ten-day international North Atlantic Treaty Organization conference in 1975, Hare began developing his Psychopathy Checklist. Produced in 1980, it was based partly on the list of traits advanced by Cleckley and partly on the theories of other authors and on his own experiences with clients in prisons. Meanwhile, also in the wake of the NATO conference, a DSM-III task force instead developed the diagnosis of antisocial personality disorder, published in the DSM in 1980. This was based on some of the criteria put forward by Cleckley but operationalized in behavioral rather than personality terms, more specifically related to conduct. APA was most concerned to demonstrate inter-rater reliability rather than necessarily validity.

Nevertheless, one author referred to the concept of psychopathy in 1987 as an "infinitely elastic, catch-all category". In 1988, Blackburn wrote in the British Journal of Psychiatry that as commonly used in psychiatry it is little more than a moral judgment masquerading as a clinical diagnosis, and argued that it should be scrapped. Ellard argued similarly in the same year in the Australian and New Zealand Journal of Psychiatry, describing the concept as 'a reflection of the customs and prejudices of a particular social group. Most psychiatrists are from that group and therefore fail to see the incongruity.' By the 1970s and 80s the sexual psychopath laws were falling out of favor in many states; the Group for the Advancement of Psychiatry called them a failure based on a confusing label mixing law and psychiatry.

Hare revised his checklist (PCL-R) as a draft in 1985 (removing two items) and then finalised it as the first edition in 1991. Meanwhile, following some criticism over the lack of psychological criteria in the DSM, further studies were conducted leading up the DSM-IV in 1994 and some personality criteria were included as "associated features" which were outlined in the text. The World Health Organization's ICD incorporated a similar diagnosis of Dissocial Personality Disorder. Both state that psychopathy (or sociopathy) may be considered synonyms of their diagnosis.

Hare updated the PCL-R with extra data in a 2nd edition in 2003. He has also written two bestsellers on psychopathy, "Without Conscience" in 1993 and "Snakes in Suits: When Psychopaths Go to Work" in 2006. Cleckley had described psychopathic patients as "carr[ying] disaster lightly in each hand" and "not deeply vicious", but Hare presented a far more malevolent picture, and the "mask of sanity" acquired a more sinister and Machiavellian meaning.

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