A subset of these individuals lack a conscience; that is, they can commit all kinds of heinous, criminal acts and not care about it, not care about what the victim goes through. They lack empathy, and that's what can make some people really dangerous: that they can commit some kind of criminal act and just not care about how it impacts other people. This is what's frightening about the disorder.
Rob Kall: So, you know - I have to say, I've got a list of questions here. Well, let me hold back. How does this disorder relate to evil?
Donald Black: That's an interesting question, and I do address that in the book. I basically sidestep the issue by saying, "Evil is a philosophical or religious concept that, in my view, has no place in medicine or Psychiatry." Certainly people commit acts that you or I might call evil. For example: Osama bin Laden and the Twin Tower disaster of 2001. That was an evil act. I think most people would say that is the probably about the most evil thing someone could do, and then we saw him on videotape laughing about it. Thousands of people dead, and then he's laughing about it. I characterize that as evil. Or, think of a serial killer like Ted Bundy or John Wayne Gacy, who was torturing or murdering someone essentially for his own twisted pleasure. That to me is evil. However, as a psychiatrist, I don't use that term in my daily practice, and I wouldn't encourage my trainees to use it either, because it has religious and/or philosophical connotations that I don't think are appropriate for mental health professionals to be discussing.
Rob Kall: That's fair enough in terms of talking about Psychiatry; but you're an expert on sociopathy, so I'm kind of asking you also from the perspective of culture, and the perspective of how evil is conceptualized. It just seems to me that evil is perpetrated by sociopaths.
Donald Black: Well, a lot of it is, but then you could argue that Osama bin Laden does not meet the definition of a sociopath, because he doesn't have all of the cardinal symptoms that we would expect for that disorder, including a history of childhood misconduct. So even non- anti-social people can commit evil acts. Now, I do make the argument in my book that Saddam Hussein probably was a sociopath and would have met our definition. We have specific criteria that we use to make the diagnosis, because he has a documented history of misbehavior going back to early childhood, and continuing until the time that he was (essentially) caught and incarcerated.
Rob Kall: Another
thing you say in your book is, "They rebel against every type of regulation and
expectation, seemingly oblivious to the value of living within societies
boundaries. Despite all sanctions,
parental punishment, ostracism, failure, or jail, they remain stuck in a rut of
Donald Black: Yes, absolutely. They don't like rules, they don't like regulations, and they don't seem to learn from the bad consequences of their behavior. They are stuck in that rut that they can't seem to get out of. Now, as some of them get older they do seem to climb out of that rut, because anti-social behavior in general tends to subside as people get older. It's unclear why. Maybe they're more mature, maybe they're just too tired to act out, who knows; but they do tend to improve over time.
Rob Kall: Now, that description, somebody "resisting regulations and expectations," it can also apply to protestors, dissidents. And in other countries, sometimes dissidents have been jailed under psychiatric pretexts.
Donald Black: Yeah.
Rob Kall: How do you reconcile that idea, that people who protest, people who engage in civil disobedience and get themselves arrested are -- how do you separate the protestors from the sociopaths?
Donald Black: Well, again, those sorts of things occur in a cultural context. They're not acting alone, they're acting within a large group of people - you know, other protestors that share their particular worldview - and that's outside the scope of what sociopathy or anti-social personality disorder is about. Plus, if you examine these people and took their histories, most of them would not have a history of childhood misbehavior, they wouldn't have a history of adult criminality, they wouldn't be abusing their spouses, they wouldn't be getting into trouble at work, and so forth. So I think even in countries where these kinds of acts can get you arrested, most people would be able to distinguish between the sociopath who was regularly getting into trouble, and the person who is simply violating laws that he and many other people just don't accept.
Rob Kall: Can you talk a little bit about this diagnosis and disorder, and DSM-IV and DSM-V, the diagnostic manuals for psychiatrists?
Donald Black: Yeah, well let me just talk a little bit about the history of this concept. I remember an interview that I had years ago, I can't remember who was interviewing me, but they said, "Doctor Black, so you are describing a new condition called 'Anti-social Personality Disorder.'" I said, "I'm doing nothing of the sort." In fact, if you look at the history of psychiatry over time, this concept has been around at least two hundred years (if not longer), where psychiatrists, or doctors, or others were describing people who were not psychotic (that is, they weren't hearing voices or seeing things), and yet they were regularly getting into trouble and committing criminal acts.
We've always had a segment of the population who behaves this way, and this has been described in the literature for hundreds of years, and in the late 19th century, doctors described it in more detail. In the 20th century, that tradition continued: there was a man writing in the 40s named Hervey Cleckly, an American Psychologist. He wrote a book called The Mask of Sanity that really brought these ideas together, and it was very influential book. By the way, he's also co-author of Three Faces of Eve; everyone has heard of Three Faces of Eve, they haven't heard of Masks of Sanity. Psychiatrists and psychologists look at the Mask of Sanity as really pulling this concept together.
The diagnostic and statistical manual of mental disorders, and many listeners may not be familiar with that, but it is essentially the diagnostic bible that psychiatrists and psychologists use. It's produced and published by the American Psychiatric Association, and has been since 1952 when it first came out. Anti-social personality disorder, either under that name or other names, has been there from the start. We have specific criteria to define it that can be used by clinicians in practice, it can be used by researchers, and it is a valid disorder. It's been shown to be very reliable, that is, various psychiatrists around the world seeing the same patient applying those criteria will diagnose that person anti-social.
So it's reliable, it's valid, meaning it's a highly useful concept, in that it's predictive of what happens to an individual. When someone has that diagnosis, we know a lot about that person, and we know what the possible outcome probably is. Currently, we're using the 4th edition of the DSM, as it's called, and we're about to go into the 5th edition, which will be released in late May at the American Psychiatric Association meeting in San Francisco. I'll be there. The criteria have not changed; so what's in DSM-IV will be in DSM-V.
Rob Kall: And what are the basic criteria to diagnose, the bare minimum criteria?